Consultation Request Form

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By supplying your email, you give permission to receive communications via your email address.

Email *

Full Legal Name *

Date of Birth *

YYYY

Phone Number *

Do I have permission to call or text this number? (I generally communicate via email or secure messenger, but if I am unable to reach you that way, calling would be an alternate means of reaching you.) *

Yes - Calls/voicemails and texting are ok

Yes - Calls/voicemails only, no texts

Yes - Texts only, no calls/voicemails

No - Do not contact me at this number

Required

What type of services are you interested in? (Check all that apply) *

Couples Counseling - In-person (Brainerd)

Couples Counseling - Telehealth (Minnesota/South Carolina)

Individual Counseling - In-person (Brainerd)

Individual Counseling - Telehealth (Minnesota/South Carolina)

Hypnotherapy - In-person (Brainerd)

Accelerated Resolution Therapy - In-person (Brainerd)

Accelerated Resolution Therapy - Telehealth (Minnesota/South Carolina)

Other:

Required

Briefly, what issues are you hoping to address? *

Note: If these issues are not within my scope of practice, or if I believe your needs would be better served elsewhere, I will let you know ahead of time and offer appropriate referrals.

**If you are in crisis, do not complete this form. Call 988 or go to your nearest Emergency Department.**

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This form was created inside of Theraspire Counseling Services.