Initial Screening Form
New Client Screening
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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 via your preferred method to either schedule your initial online appointment or provide you with referrals to more appropriate providers to meet your needs.

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

Full Name:
Today's Date:
Phone Number:
Do you currently reside in the state of Florida?  
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Are you available for Telehealth appointments?
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Are you seeking individual or couples counseling?
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Are you available for weekday appointments only? We do not offer late evening or weekend appointments.      
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Do you have Aetna or Cigna insurance or the ability to self pay?
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How did you find Healing with Wisdom?
Please provide a brief description of what you are seeking help with?
A copy of your responses will be emailed to the address you provided.
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