Ready to Start Therapy and Reconnect With Yourself?

Name *

First Name

Last Name

Phone *

Country

(###)

###

####

How did you hear about me? *

Social media

Word of mouth

Google search

Which of my services are you interested in?

IFS/Parts Work

Brainspotting

Coaching

Couple's Therapy

Talk Therapy

I'm not sure, can we figure it out together?

Have you ever been in therapy before?

Yes

No

Please check which time frames work you *

I currently have openings Monday-Thursday virtually during daytime hours and limited evening availability

I am available anytime

I am available only during the day between 11-4 pm EST

I am available only in the evening between 5-8 pm EST

What are you seeking help for? Please check all that apply.

Anxiety

Depression

Self Esteem

Relationship Issues

Career

Trauma

In the last 6 months, have you thought about or attempted suicide?

Yes

No

I have have had frequent thoughts

I have infrequent thoughts

Do you have insurance coverage or will you be paying out of pocket?

I have insurance/benefits

Paying out of pocket

Please confirm that you are seeking weekly or bi-weekly therapy or coaching sessions. *

Yes, I want to meet weekly.

Yes, I want to meet bi-weekly.

No, I want to meet less often (if you check this box, we are not a good fit to work together)

I am not the therapist for you if: *

- You do not want to explore your past. - You do not want to focus on your emotions. - You want me to give you answers or advice. - You want me to tell you what we will be processing/exploring each session. - You want a list of tools or a quick fix for your presenting issues. If my approach doesn't fit with you, that's okay! There are so many different approaches & I encourage you to find a therapist that best fits with your needs.

I understand and agree

I am not open to this approach (if you check this box, we are not a good fit to work together)

I am the therapist for you if: *

- You are ready to commit to regularly scheduled sessions - You are open-minded to trying new things and getting outside the box - You are wiling to put in work outside our appointments that aligns with your goals to foster change - You are serious about this process and want real, lasting results.

I agree

I do not agree (if you check this box, we are not a good fit to work together)