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Session Consultation Form
Please fill out this brief consultation form to ensure best match for services and/or be added to the waitlist.
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Email *
Full Name(s) of Client *
Referral Source (google, friend, Psychology Today, etc.) *
Contact Number *
DOB (mm/dd/yyyy)
Gender *
Location (City/State) *
What services are you looking for? *
Brief reason for referral *
What do you need from a therapist?
Will you using insurance or private pay? *
Which health insurance do you have? Please note that I do not accept Medicaid plans at this time. (N/A if not applicable) *
Do you have secondary insurance? If so, please list below. *
What days/times are you available for sessions? Please note that I do not have weekend availability and my current evening slots are very limited. *
When are you looking to start sessions? *
Is there anything else you'd like to share?
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