Initial contact
Completing this form will help us get started. This information goes directly to me (Angie Leek) and only me. Your information is secure, using a HIPAA secure email platform. Please be brief with any clinical information and know that filling out this information does not constitute a client/therapist relationship. My hope is that this will help us get started and will hopefully eliminate phone tag and waiting to get in touch. I respect your time and your motivation to get started with counseling. If my schedule is full, I'll let you know right away and can make recommendations for other therapists if needed -or, if I have space for new clients, we can talk further to determine fit and possibly schedule an initial apt.
What is your name? *
Your answer
What is your email address? *
Your answer
phone number *
Your answer
If I call you, it is ok to leave a voice mail message? *
Is it ok to text for basic contact/scheduling (I do not text clinical information)
How did you hear about me? *
Please explain (if other, a friend, etc.)
Your answer
What brings you to counseling at this time? *
explain/expand if needed (in a few words)
Your answer
Do you have health insurance that you'd like to use?
Generally speaking, what is your availability for meeting for an appointment
Your answer
Is there a specific specialty of mine that you are interested in talking to me about? If so, please explain
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Holos Counseling. Report Abuse - Terms of Service