Therapy Inquiry Form
For Individual or Group Therapy
Name:
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Are you (other the prospective client) currently living or will be moving to Florida, Colorado, or Idaho?
*
Yes
No
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Pegasus Counseling Services, LLC does not accept insurance at this time. Are you able to and prepared to do private pay options?
Yes
No
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Who are you inquiring about therapy services for?
*
Myself (I'm 18+ years old)
My Child (under 18 years old)
Myself (I'm under 18 years old)
My Child (18+ years old)
My Spouse
My Parent
My Sibling
Other
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What types of therapy are you wanting to engage in?
*
Individual
Group
Couples
Family
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What topics are you interested in working on in therapy? (Select all that apply)
*
Addiction/ Substance Use
Anxiety
Burnout
Codependency
Domestic Violence (Survivor)
Relationship Patterns
Toxic Relationships
Grief & Loss
PTSD
Boundaries
Self-Esteem
Sexual Violence (Survivor)
Women's Issues
Life Transitions
Depression
I'm a therapist seeking therapy
After your inquiry is submitted and it is determined that we may be able to assist you, we will reach out to you via phone to complete a mandatory 15 minute phone consultation to review your interest and determine goodness of fit. This consultation is at no charge to you. Please list all the days and times that it is the best time for us to call you for this consultation.
*
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