Consultation Request Form

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Do not give any detailed personal information outside of the specific questions to protect your own personal privacy.

This consultation form is to help determine if "on paper" we would be a good fit for one another. Sometimes during a consult a possible client and therapist may hit it off well with specialty and then get to schedule and payment and that part doesn't match or fit. I want to make sure we "match" with what my schedule allows for and my insurance and payment options so you are not investing hope in a therapist you won't be able to work with.

Please answer the questions below and I will be in touch within the coming days.

Email *

First Name of person filling out form, if not identified client (NO LASTNAME)

First Name of person seeking therapy (NO LASTANAME) *

Are you looking to use your medical insurance to cover part or all of your therapy? (I accept Premera as In Network & will bill all other insurances as Out of Network) *

Yes

No, I plan to do cash pay

Other:

What insurance company are you covered under? *

I work Tues - Fri during school hours only, no after school or evening hours. Pick the days and times that are most convenient for you. (day and time are not guaranteed) *

Tues (AM) *tele-health ONLY*

Tues (PM) *tele-health ONLY*

Wed (AM) *in-person & tele-health*

Wed (PM) *in-person & tele-health*

Thurs (AM) *in-person & tele-health*

Thurs (PM) *in-person & tele-health*

Fri (AM) *tele-health ONLY*

Required

Check all that apply as to why you are seeking out therapy *

Anxiety

Depression

Infertility

Conception / Pregnancy / Postpartum

Trauma

Life Changes

Relationship

Parenting

Work

Other:

Required

What type of therapy are you looking for? *

Parenting Intensive Therapy (I take 1-2 families a month, a longer more extensive consult is required to determine if your family is a good fit)

Women's Mental Health Therapy

Perinatal Mental Health Therapy

EMDR Therapy (can also be done in conjuction with Women's or Perinatal Mental Health Therapy)

Professional Consultation or Speak Engagement

Not sure, just know I am looking for support

Required

Would you like to be contacted for free 20 min video consultation to see if working together would be a good fit?

(making a profile in Simple Practice and adding insurance and credit card required for a consult)

Yes

No, but maybe in the future

Other:

Send me a copy of my responses.

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This form was created inside of Emma Kowalinski, MS, LMFT, MDFT.