Initial contact

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Initial contact

Completing this form will help us get started. We will get back to you by email or phone as soon as possible to discuss next steps.

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.

I respect your time and your motivation to get started with counseling.

Email *

What is your name? *

phone number *

If we call you, it is ok to leave a voice mail message? *

Yes

Yes but only discreet/generic voice mail (I.e. do not reference mental health counseling)

Is it ok to text for basic contact/scheduling (we do not text clinical information)

Yes

Clear selection

How did you hear about Holos Counseling? *

A friend

Another Therapist

Insurance / EAP

Holos Cousneling Website or FB page

Psychedelic Support or MAPS integration list (or similar)

other

If your answer above is: "A friend"/"Another Therapist" or "Other", please elaborate:

What brings you to counseling at this time? *

Depression/Anxiety

Stress/Transition/Life direction

Relationship issues

Couples counseling

Spirituality/mindfulness

Psychedelic Integration

Other

explain/expand if needed (in a few words)

Would you like to work with a specific provider?

Teri Honeysuckle LAC - sliding scale (can't bill insurance)

Kati Street: PhD, LAC - counseling for individuals on a sliding scale (accepting ambetter and BCBS)

Jason Leek: Psychedelic Integration coaching $50-100 sliding scale (can't bill insurance)

Julie Wilson: holistic financial coaching - $100

Angie Leek LPC/LMFT-S is currently full and not accepting waitlist clients at this time

Clear selection

Do you have health insurance that you'd like to use?

BCBS

Ambetter

UMR

Lyra

Other/out of network

Self Pay

I would like to discuss sliding scale options

Clear selection

Generally speaking, what is your availability for meeting for an appointment

I understand that the counselors and coaches at Holos Counseling are not able to provide psychedelic medicine or psychedelic assisted therapy at this time, nor are they able to help you find someone who does. These medicines are currently illegal outside of the context of a clinical trial setting. We can provide psychedelic INTEGRATION counseling/coaching only. *

I understand

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