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Potential Client Application
Please answer the following questions so that I can be prepared to determine if you are a good fit for becoming a therapy client in my practice
Email address *
What is your name?
Your answer
Please let me know the best phone number to call you on and a couple of good times to reach you. If there is a number I can text you on before I call (to make sure it's a good time), please also let me know that here.
Your answer
A couple of FYI's- Before you complete this form
Since this question comes up often, I wanted to let you know that I'm not in network for any insurance plans. I take payment by cash, credit card, or check after each session. If you have out of network benefits and are eligible for reimbursement from your insurance, I will be happy to give you a claim form to submit to them (I can sometimes also submit claims on your behalf electronically depending on which insurance plan you have).

The fee I charge for therapy is $200 per session for individual therapy and $250 for couples therapy. Sessions are 45 minutes. On occasion, I agree to reduce my fee a little bit if there are issues of financial hardship or if someone wants to come multiple times per week and needs a reduced fee to make this affordable. However, if you are looking for a very low-fee or someone who takes your insurance, I would need to refer you to a different provider who can work with that. I will be happy to try to help with this if needed.

I also want to let you know that I take payment for the first session by credit card (over the phone) at the time of booking. The reason I do this is because therapy is a big step and many people get "cold feet" after they make the initial phone call. This is not unusual and very normal. It's not uncommon at all for a person to reach out to a therapist at a moment of urgency, and then, as soon as the feeling of urgency passes, to change their mind about the whole thing. This is one of the main reasons why so many people lose so much time before they actually follow through on getting the help they need. It's just more comfortable to try to fix things ourselves and it's scary and sometimes also embarrassing to get help. It's certainly a very vulnerable feeling to have to go see a therapist, and some people have also had negative experiences in the past which makes it hard to want to try therapy again.

One way I've found to help people make the commitment to follow through on coming to the therapy session, even if there are feelings of ambivalence, is to just take payment at the time of scheduling the first appointment. It just makes the follow through easier. Many people also like knowing that the session has already been paid for when they come in for the first session. Once you do come in for your session, we can certainly talk about any fears or doubts you have, and I will do my best to help you work them through...but at least you will have shown up!!

1. Which issues are you looking to work on in therapy? *
Required
2. What have you already tried to solve this problem?
3. What is your reason for seeking therapy right now?
4. What barriers to following through on therapy apply to you right now:
5. What costs will there be to not solving this problem at this time?
6. What qualities in a therapist are most important to you at this time? *
Required
7. What is your desired result or transformation?
8. Any additional comments or questions about your answers above (or in general) before we speak? *
Your answer
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