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Prospective Client Interest Form (Updated)
This form serves as a screening tool to assess whether or not I am the best fit for you and to gather information prior to a free 15 min. consultation call, should you request one.
Email *
Legal First and Last Name:
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Please tell me the name you'd like me to address you by, if different than your legal name (listed above), (and your pronouns if you'd like), so that I may refer to you correctly.

For example, Becky she/her (as opposed to Rebecca she/her)
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How did you hear about Carey Milne Therapy? 
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If you selected Other, Other Therapist/Healthcare Provider or Friend/Personal referral above, please provide their name.

Note that if it is a current or past client, know that I will not be able to confirm or deny my relationship with them, or lack thereof. 
Are you aware of any conflicts of interest prior to beginning therapy with me? 

(i.e. knowing that a friend or a family member is a current client of mine)
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Have you ever been in therapy before?
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If 'Yes', when was this and, briefly, what were you being seen for?

Please type N/A if above answer was 'no.'
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How do you plan to pay for services?
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As I am only offering virtual appointments at this time, do you have a private space to engage in teletherapy?
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Due to telehealth/licensure laws, I can only see clients who are physically located in Nevada, Utah, or Virginia, or Washington D.C at the time of appointment. Please select which option best describes your residency situation.
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What are your concerns at this time? What are you hoping to work on/address in therapy? You can be brief.
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What are your goals for therapy? What are you hoping to gain from therapy? What do you want your life to look like as a result of our work together?
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Please check all boxes that apply to you presently OR in the past. If none apply, please select that box. 

These are not immediately disqualifying, but will need to be further discussed to see if I am an appropriate fit for your needs at this time.
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Required
Do you have any questions for me that you want me to answer via email prior to our consultation? (i.e. regarding treatment modalities, personal/professional values, practice policies, etc.) If you would prefer to ask during our consultation, you may do so.
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When are you available to meet for regularly scheduled sessions? Check all times that apply: 

Listed below are all of my working hours, to gain an understanding of how aligned our schedules are. This is not an accurate representation of open time slots.
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Any time on this day
No availability on this day
7 am PT
8 am PT
9 am PT
10 am PT
11 am PT
12 pm PT
1 pm PT
2 pm PT
3 pm PT (not always available)
Monday
Tuesday
Wednesday
Thursday
If you have a strong preference for a certain hour or time slot listed above, you may note here. 
Are you interested in me contacting you to schedule a free 15 min. phone consultation prior to scheduling an intake appointment or are you interested in being contacted to schedule an intake appointment right away?
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