Behold Counseling - Consultation Questionnaire
Email *
Your First & Last Name (if you are requesting couples sessions, please also include your partner's name) *
Email address *
Phone Number *
State your preferred way to be contacted for scheduling a consultation *
Please specify which type of service you are interested in *
Your Message / Reason for your inquiry / Any questions you have for me *
Have you had any previous experience with therapy? If so, please describe your experience? *
If you seeking individual sessions, please rate the average level of distress you are feeling
Feeling content most days
Feeling intense emotions & have harmful thoughts
Clear selection
If you seeking couples sessions, please rate the current level of distress in experienced within your relationship
mild arguments, able to resolve issues calmly for the most part
intense arguments (yelling, slamming doors, throwing objects, etc)
Clear selection
If we decide to move forward following our consultation, what form of payment do you plan to use for sessions? 
 *
If you require a sliding scale, please explain your financial situation and your estimated budget for sessions
Please provide potential weekly hour slots you are available for consultation & therapy meetings *
Who referred you to this practice? *
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