Beyond Better Health Consultation Form

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Thank you for your interest in working with me! I would love to meet with you to discuss how I can support you all on your journey. I would love to explore the possibility of us working together and would like to get to know a bit better to ensure we are a good fit for one another and when we can begin! Please answer each question below. I will then provide some options on how we can proceed via email.

Adetoun Adeyemo, LCSW

Beyond Better Health Counseling and Consultation LLC

Email *

First name
*

Last name
*

Phone number *

Do you live in Georgia or Indiana? *

Yes

No, I understand I will receive a referral

Sessions are available Monday-Thursday 7a-3p
*

This works for me!

I need availability after 3p and understand I will need a referral.

Sessions are Telehealth only
*

This works for me!

I prefer in person sessions and understand I will need a referral.

Please briefly describe the types of issues that you are seeking therapy for.
*

Aetna

United Healthcare

Oxford

Oscar Health

Self pay $150

Please briefly describe the types of issues that you are seeking therapy for.
*

Aetna

United Healthcare

Oxford

Oscar Health

Self pay $150

How were you referred to us?
*

Thoughts, plans or attempted suicide? *

Yes

Thoughts of hurting others?
*

Yes

Issues related to self harm?
*

Yes

Hearing voices or seeing things other people do not?
*

Yes

An inability to control your behavior when emotional?
*

Yes

Please provide a brief explanation to any questions marked 'yes'
*

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