New Client Interest Form

Thank you for your interest in becoming a potential new client with Evergreen Therapy/Ashley Lanier-Pszczola LMFT!

Below you will be able to schedule a free 15 min consultation phone call where we can discuss working together. Please also complete the questions below so I can learn a little more about what you're looking for from therapy so we can make the most of our call.

If we decide we are a good fit, we can schedule the initial session before we end our call.

This form should only be completed by ages 18+. If you are a teen interested in services, please complete this form with your parent.

Free 15 Min Phone Consultation

Email address

example@example.com

Are you filling out this form for yourself or another person?

First and Last name of the potential client

Date of Birth of potential client

MonthDayYear

If you are filling out this form on behalf of someone else, what is your first and last name and relation to the potential client?

Email address of potential client (or parent/guardian if client is a minor)

Phone number of potential client (or of parent/guardian if client is a minor)

How did you find Evergreen Therapy? (If another provider/person referred you, please list their name under "other" so I can thank them!)

Other

Type of therapy you're primarily interested in:

Other

Please describe in a few sentences the reasons for seeking therapy services

Has the potential client ever engaged in self-harming/self-injurious behaviors?

Has the potential client experienced any suicidal thoughts/wish to be dead?

Has the potential client been hospitalized for mental health reasons?

Client Preferences: Types of Sessions

Client Availability: Please list days/times that would typically work well for you for sessions, or any specific scheduling restraints you have. Please note that my availability for sessions is Monday-Friday 8:30am-4:00pm.

Evergreen Therapy/Ashley Lanier-Pszczola LMFT is a fully self-pay practice and does not accept insurance of any kind. Clients must pay for therapy at the time of service via credit, debit, or HSA card. Rates are $195-$230 for hourly sessions depending on the type, and $250 for the intake session. Rates are also outlined in detail on the website under Services and FAQs.Evergreen Therapy can provide clients with a monthly super receipt to submit to their insurance on their own. Please confirm that you have reviewed the fees and are ready and willing to pay out of pocket for services.