Therapy Interest Form

Thank you for reaching out.  I'm glad you've taken the time to begin this process.

This short form helps me understand what you're looking for so I can guide you toward the right next step. You can use it to:

  • Request a consultation for an EMDR or Brainspotting Intensive, or
  • Join the list for weekly individual therapy, or to hear about upcoming groups, events, and resources from the practice.

However you found your way here, I read every message personally and will follow up within 1-2 business days.  

Your privacy matters. ShaQuan Read Counseling & Consulting uses a paid, HIPAA-compliant Google Workspace to keep your information secure and confidential.

Sign in to Google to save your progress. Learn more
Email *
First Name *
Last Name *
Pronouns
How were you referred to ShaQuan Read Counseling? (Check all that apply) *
Required
If you were referred by another therapist,  doctor , or provider please share their name so I can thank them for being a referral partner. 
Will you be residing in Massachusetts at the time of services? *
Phone Number *
Date of Birth *
MM
/
DD
/
YYYY
Will you be using insurance or self-paying? *
Required
What type of services are you looking for? *
Required
Consultations & Waitlist *
Are you currently working with another provider *
Required
Availability (Days/Times) *
What are your main goals for therapy? Or, what areas of your life do you hope will change or improve through your experience in therapy? *
Is there anything else you'd like us to know?
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