New client inquiry

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New client inquiry

If this is a mental health crisis, please do not complete this form. Contact 988 or go to your nearest emergency room.

Please note that submitting this form does not place you on a waitlist or guarantee that you or your child will receive services now or in the future, and it is not a consent to treatment. Offer of services depends on clinician fit and availability.

The email account for new clients is not monitored daily; however, under most circumstances, you can expect to hear a response within 2 business days. If you are a current client, please reach out to me directly using the contact information that provided to you.

Your name *

Child's name (if client is under 18)

Child's age (if client is under 18)

Email *

Phone *

Reason for seeking services *

How would you prefer I get in touch? *

Phone

Either option is fine

Please review and acknowledge: *

I acknowledge that all services provided by Dr. Kratz are delivered via telehealth; no in-person services are available at this time.

Required

Please review and acknowledge: *

I acknowledge that electronic communication is limited in terms of privacy and may be intercepted by a third party. I also acknowledge that this electronic communication does not constitute a therapeutic relationship.

Required

Please note that you will NOT receive an email copy of the form, because there is not a HIPAA-compliant way to send a copy of the form to you. If you would like to keep a copy for your own records, please screenshot the form before you hit “submit”.

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This form was created inside of Hilary Kratz, PhD, LLC.