ShaQuan Read Counseling Client Info Form

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Please include your information below to schedule an EMDR/Brainspotting Intensive Therapy Consultation

To be placed on our waitlist for individual therapy and/or to learn more about upcoming groups, events, resources offered by our therapy practice. SRC uses a paid HIPPA Compliant version of Google Workspace to keep your information private.s

Email *

Will you be residing in Massachusetts at the time of services? *

Yes

No (I am only licensed in MA and cannot provide services outside of the state. I would be happy to provide a referral if you are out of state.)

How were you referred to ShaQuan Read Counseling? (Check all that apply) *

ShaQuan Read Counseling Website

Therapy for Black Girls

Psychology Today

Clinicians of Color Directory

Inclusive Therapists

Therapy Den

Thriving Campus

Liberation Focused Therapists

MA/RI Clinicians of Color Directory

Another Therapist

Primary Care Physician

Family/Friend

Other:

Required

If you were referred bya friend, family, another therapist or doctor please share their Name. I will not contact them.

Last Name *

First Name *

Pronouns

Phone Number *

Email Address *

Date of Birth *

YYYY

Will you be using insurance or self-paying? *

Blue Cross Blue Shield of Massachusetts

Harvard Pilgrim

Allways

Optum

Health Inc

Tufts

Self -Pay - Not using Insurance

Other:

Required

What type of services are you looking for? *

EMDR/Brainspotting Intensive Therapy

Individual Counseling (Waitlist)

Group Therapy

Coaching

Clinical supervision/consultation (Clinicians Only)

EMDR Certification Consultation (Clinicians Only)

Other:

Consultations & Waitlist *

I would like to Schedule a consultation for EMDR/Brainspotting Intensive Therapy Sessions

I would like to be added to the Waitlist for Individual Counseling Sessions

I would like a referral to a therapist who may have openings

I would like to Schedule a consultation for Clinical supervision or consultation (Clinicians Only)

Are you currently working with another provider *

Yes I currently have a therapist and I am looking to switch to a new one

Yes I currently have a therapist and I would like to request adjunct EMDR or Brainspotting sessions only.

I am working with psychiatrist

I do not currently work with any mental health professionals

Required

Availability (Days/Times) *

Is there anything else you'd like us to know?

Please briefly describe what you would like help with. *

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