First Responder Support – Intake & Rate Placement
This brief form helps me understand your situation so I can offer the most appropriate rate and support options. All responses are confidential and used only to determine the best fit for your care.
Basic Information:
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Preferred method of communication.
*
Please Select
Phone
Email
Best time to reach you:
*
Please Select
Morning
Afternoon
Evening
Role & Background:
What best describes your role?
*
Please Select
Law Enforcement
Fire
Corrections
Probation
Military
Dispatch
Other
If other, please describe.
Are you currently working in this role?
*
Please Select
Yes
No
Recently left
Financial Snapshot:
What is your approximate annual income range?
*
Please Select
Under $60,000
$60,000 – $75,000
$75,000 – $90,000
$90,000+
Are you currently experiencing financial strain that impacts your ability to pay for services?
*
Please Select
Yes
Somewhat
No
Pricing Alignment:
*Final session rates are determined after review to ensure the best fit for your situation and to maintain sustainable care.
Which of the following ranges feels most sustainable for you right now?
*
Please Select
$90 – $110
$120 – $150
$160 – $200
Commitment & Expectations:
Are you open to reassessing your rate after a few sessions if your situation changes?
*
Please Select
Yes
No
What is bringing you in for support right now?
*
Submit
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