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Suzanne Horton LMHC-Consultation Questionnaire
15 minute video consultations are required to support evaluating good client provider fit for services
Please provide the information below to request a 15 minute video consultation
Currently consultations are available Tuesday @8:00 & 8:30 am, Wednesdays @12:00 & 12:30 and Thursdays @3:00 & 3:30pm
Upon submitting form a link will pop up in the thank you message for you to schedule a consultation.
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* Indicates required question
Email
*
Your email
Name
*
Your answer
Age Range?
*
18-28
29-38
39-48
49-58
59 and up
Other:
Required
What Brings you to Counseling?
*
Anxiety
Communication skills
Emotional Intelligence
Grief & Loss
Parenting
Relationships
Stress Management
Work Life Balance
Other:
Required
What are you looking for in a provider?
*
Your answer
Please list any questions that you have for provider
*
Your answer
What is your awareness of self's contribution to identified issues?
*
Your answer
What is your readiness for change within identified issues?
*
precontemplation- don't see a problem
contemplation- thinking about it
Determination- considering steps to take
Action- taking steps
Maintenance- proactive use to manage issues
How often are you interested in being seen
*
weekly
every other week
Other:
Required
Please share at least 3 specific days and times that you are available for scheduling.
*
Your answer
Please share resource you found provider through
*
insurance directory
shortonlmhc.com
employee assistance program (EAP)
psychology today
therapist.com
word of mouth
Other:
Required
By completing a consultation request with Suzanne Horton LMHC you understand that services are:
on a weekly or biweekly basis
available Tuesday, Wednesday & Thursdays 8:00am to 6:00pm
on a specific/ consistent schedule ie... Tuesday @3pm weekly or Thursday @9am every other week
through Telehealth only- live video sessions
across Washington State only
Resources
988 National Suicide Hotline
211 Community Resources statewide
Psychology Today
Therapist.com
Insurance Directory
perinatalsupport.org
mobilemama.com
PAVE- parent/ student support for IEP & 504 plans
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