Contact Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Contact Form

Full Name *

Please enter your name as you'd like to be addressed

Email Address *

We'll use this to contact you about scheduling

Phone Number *

A number where we can reach you for scheduling

Preferred Contact Method *

How would you prefer we contact you?

Phone

Text Message

Service Interest *

Which service(s) are you most interested in exploring?

Individual Therapy

Brainspotting Therapy

Consultation (Mental Health Practitioners)

Required

Location *

In which state will you be physically located during sessions?

North Carolina

New York

New Jersey

South Carolina

Language Preference *

Do you have a preference for the language of your therapy session?

English

Spanish

No Preference

What health insurance do you have? *

Aetna

Blue Cross Blue Shields

United Healthcare

Optum

Oscar

Oxford

Other:

Have you had psychotherapy in the past?* *

Yes

What brings you to therapy at this time? *

Briefly describe what brings you to therapy. You can list concerns such as anxiety, trauma, ADHD, grief, depression, stress, burnout, life transitions, or anything else you'd like support with.

Is there anything else you would like us to know before we contact you? (Please do not include detailed health information in this field)

Consent To Contact *

I consent to being contact by Hernandez LCSW, PLLC at the contact information listed above

Required

Privacy Acknowledgement *

I understand that this form is for initial contact purposes only and that no therapeutic relationship is established by submitting this form

Required

Submit

Clear form

Never submit passwords through Google Forms.

Forms

This form was created inside of Elaina Hernandez LCSW PLLC.