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Screening
Please complete this form to be referred to intake or your chosen therapist.

Contact Kati at admin@affirmativetherapycollective.com to follow up on wait times or to ask any questions, including those about specific therapist availability, or about this form, or for assistance with matching you with a therapist who can help. 

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Email *
Full name: *
What state are you located in? *
Pronouns:
Phone number: *
Date of birth: *
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Preferred method of contact: *
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Therapist I am most excited to work with: *
Are you open to seeing other therapists in our practice in order to get started more quickly? *
How would you like to meet? *
Do you have any scheduling needs, preferences, or restrictions? (Use other to request specific days or times) *
Are you hoping to use out of network insurance to reimburse you for your session costs? 

You can check your out of network benefits on our website here: https://affirmativetherapycollective.com/benefits-check/

Please let us know your results below.

If no, please enter N/A.
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Fees vary by therapist but range from $175 - $250 for individual therapy and $200 - $300 for couples/relationships/families. Will you need a sliding scale or reduced fee in order to begin weekly therapy?  *
What are you hoping to work on in therapy?  What do you hope to get out of therapy? *
What are you looking for in a therapist? Use this space for requests around therapist identity, area of specialty, approach, vibe etc. *
How did you hear about us? *
Anything else you'd like your therapist to know about you? *
A copy of your responses will be emailed to the address you provided.
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