Initial Screening Form
New Client Screening
Sign in to Google to save your progress. Learn more
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 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 kerrianne@healingwithwisdom.net.

Full Name:
Today's Date:
MM
/
DD
/
YYYY
Phone Number:
Do you currently reside in the state of Florida?  
Clear selection
Are you available for Telehealth appointments?
Clear selection
Are you seeking individual or couples counseling?
Clear selection
Are you available for weekday appointments only? We do not offer late evening or weekend appointments.      
Clear selection
Do you have Aetna or Cigna insurance or the ability to self pay?
Clear selection
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.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Healing with Wisdom. Report Abuse