Cultivate Counseling Intern Waitlist Form

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www.cultivatecounselingflagstaff.com

Hello! Thank you for thinking of Cultivate Counseling for your counseling and mental health needs.

Please take a minute to fill out the form below as this will help us get you scheduled as soon as possible. There is no commitment and if you find someone sooner you can just let us know when we call you.

If you have any further questions you can call us at 928.865.5024 or email us at office@cultivatecounselingflagstaff.com.

First and Last Name *

Preferred name and pronouns

Phone Number *

Email Address *

Why don't we start with you telling a little bit more about what you're looking for? Is there any specific topic that you'd like to focus on? *

Thank you! Next let's get some details from you.

What is your current substance use?

No current alcohol or drug use

Current alcohol or drug use, with minimal impact and/or interruption to daily life

Current alcohol or drug use, with some impact and/or interruption to daily life.

Current alcohol or drug use, with significant impact and/or interruption to daily life.

Clear selection

If in recovery, for how long?

(Note: Cultivate Counseling only has a few therapists trained in alcohol and drug use recovery. The wait for these therapists can be significantly longer. We recommend reaching out to the following local agencies if acute care is being needed: The Guidance Center, Southwest Behavioral Health and Back2Basics.)Untitled Title

Have you had a recent mental health hospitalization in the last 30 days?

Yes

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How did you hear about us?

Is there a specific Supervised Intern you are hoping to work with at Cultivate Counseling? (Please refer to our website for each therapist's area of specialty https://www.cultivatecounselingflagstaff.com/therapists-1) *

Hannah Hackett, Supervised Intern

Lauren Schneidewent, Supervised Intern

Any Supervised Intern will work

Are you willing to see another supervised intern if your preferred intern is full? (please note that by answering "no" the wait could extend beyond the quoted timeframe) *

Yes

Notes on Availability (any specific details you can offer regarding days and times are very helpful) *

Are you willing to come in if there is a Cancellation? *

Yes

What is your date of birth? *

YYYY

Our current rate for seeing supervised interns is $50.00 per session and they do not accept insurance. Does this work for you? *

Yes

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