Dr. Anastasia Walker — Consultation Request
Welcome, and thank you for taking this step. Reaching out takes courage and I don't take that lightly. This brief form helps me understand your needs and determine whether my practice is the right fit for you at this time. There are no wrong answers — just be honest. If it seems like we'd be a good fit I'll be in touch within 48 hours to schedule your free 15-minute consultation. If it doesn't seem like the right fit I will still follow up with a personal email and referrals to help you find the support you're looking for. You will not be left without a next step.
Name
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First Name
Last Name
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
To work with me clients must be 18 years of age or older. Are you 18 or older?
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Yes
No
Are you seeking individual therapy or couples therapy?
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Individual therapy
Couples therapy
A note on insurance and couples therapy:I'm self-pay only for couples work. Here's why: insurance only reimburses when one partner receives a mental health diagnosis and treatment is aimed at that individual's condition. Couples work doesn't fit that model — the focus is your relationship, not one person's diagnosis. Billing insurance would mean assigning one of you a diagnosis that may not be accurate, which then becomes a permanent part of that partner's medical record.Do you understand and accept that couples therapy is self-pay only?
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Yes, that makes sense to me
I have questions about this
I am seeking individual therapy
My couples therapy self-pay rates are $300 for the intake, $250 for 52-minute sessions, and $200 for 45-minute sessions. Does this work for you?
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Yes, I'm comfortable with these rates
No, this doesn't work for my budget
NA/ Im seeking individual work
For individual therapy: I accept Blue Cross Blue Shield, Aetna, Anthem, Cigna, Optum, and United Healthcare. Do you have one of these plans or will you be paying out of pocket?
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Yes, I have one of Dr. Walker's accepted insurance plans
I will be self-pay
Possibly — I'd like to discuss
If not using insurance for individual therapy, My self-pay rates are $250 for a 60-minute individual session. Does this work for you?
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Yes, I am comfortable with these rates
No, these rates do not work for me
I have insurance
NA/ Im seeking couples work
I currently see clients virtually in North Carolina only. Will you be located in North Carolina for all of your sessions?
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Yes
No
All of my sessions are held virtually — I do not offer in-person appointments at this time. Are you comfortable attending sessions online via video?
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Yes, virtual works for me
No, I prefer in-person sessions
My schedule is Monday through Thursday, 8:00 AM – 2:00 PM. Does this work for your schedule?
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Yes
No
Possibly — I'd like to discuss
I want to make sure you get the right level of support. Are you currently experiencing a crisis or feeling like you may need more than weekly outpatient therapy right now?
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Yes
No
Possibly — I'd like to discuss
I'd love to hear a little about what's bringing you here. What's going on for you right now that made you reach out?
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What are you hoping will be different as a result of working together? What does feeling better or more like yourself look like for you?
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Is there anything else you'd like me to know before we connect? This is your space — share whatever feels important.
One last thing — by submitting this form you understand that completing this consultation request does not guarantee services. The next step is a free 15-minute conversation to explore whether we're a good fit for each other. You will hear back from me within 48 hours regardless of the outcome — if it doesn't seem like the right fit I will send a personal email with referrals to help you find the right support.
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I understand and agree
Submit
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