Soul Healing Psychotherapy (Texas) Waiting List
We're opening another office in the Greater Houston Area in the Fall of 2025! All responses are kept confidential.
Full Name
*
First Name
Last Name
Email (please double check for accuracy!)
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Are you a resident of Texas?
*
Yes
No
What is the primary reason you are seeking therapy services?
*
Have you been in therapy before?
*
Yes
No
What is your preferred method of therapy delivery?
*
In-person.
Telehealth (virtual).
I am open.
Do you currently have insurance that covers psychotherapy?
*
Yes
No
Unsure
Will you pay for sessions with insurance or out of pocket? NOTE: We will begin accepting insurance in the Summer of 2026. Self-pay rate is $150/session.
*
I want to pay out of pocket.
I want to use my insurance.
I am unsure at this time.
Who is your insurance provider?
*
How did you hear about Dr. Smith?
Please Select
Friend
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Other? Please Specify.
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