New Client Screening Form
New Client Screening
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Email *
Thank you so much for reaching out!
Please complete the questions below and submit this form. Once I review your information, I will be in touch to either schedule your first online appointment or provide you with referrals to more appropriate providers.

I will follow up within 48 hours once this form has been received. If you have additional questions, please feel free to send an email to I look forward to connect with you soon. 

Today's date: *
First and last name: *
Phone number: *
Please provide a brief description of what you are seeking help with? *
Do you currently reside in the state of Florida?   *
Are you available for Telehealth appointments? *
What type of services are your seeking? *
Are you available for weekday appointments only? We do not offer late evening or weekend appointments.       *
Do you plan to use insurance or private pay? (Please note that insurance cannot be used for donor evaluations or donor recipient consult appointments) *
How did you find Healing with Wisdom? Please be as specific as you can (for example if it was a google search, state what you typed in for your search).  *
A copy of your responses will be emailed to the address you provided.
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