Pre-Consultation Form
I specialize in psychodynamic depth work and currently have limited availability. Please ensure you have reviewed my website to determine if my approach is the right fit for your needs. If we align, I will reach out to schedule a consultation.
Full Name
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First Name
Last Name
Phone Number
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-
Area Code
Phone Number
E-mail
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example@example.com
Date of Birth
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Available Days/Times
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Please provide days/times you would want a session
What type of therapy are you seeking?
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Individual Therapy
Couples Therapy
EMDR
Session Format Preference
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In-Person
Virtual
No Preference
How often would you prefer to have sessions?
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Weekly
Biweekly
Every 3-4 weeks
Not sure
How do you plan of paying for therapy?
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Insurance (Please note: I do not accept insurance for couples therapy.)
Private Pay
Unsure
If you would like to use insurance, please provide your insurance type, member ID and group number below so I can verify if I am able to accept your plan.
How did you hear about me? If someone referred you, you’re welcome to let me know their name so I can express my appreciation.
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What brings you to therapy? You don’t have to share too much—just a few key points to help me see if I’d be the right fit for you.
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Are there any specific approaches or styles of therapy you're looking for?
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Anything else you want me to know before our call?
Submit
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