Potential Client Application
Please answer the following questions so that I can be prepared to determine if you are a good fit for becoming a therapy client in my practice
What is your name?
Please let me know the best phone number to call you on and a couple of good times to reach you. If there is a number I can text you on before I call (to make sure it's a good time), please also let me know that here.
A couple of FYI's- Before you complete this form
Since this question comes up often, I wanted to let you know that I'm not in network for any insurance plans. I take payment by cash, credit card, or check after each session. If you have out of network benefits and are eligible for reimbursement from your insurance, I will be happy to give you a claim form to submit to them (I can sometimes also submit claims on your behalf electronically depending on which insurance plan you have).
The fee I charge for therapy is $200 per session for individual therapy and $250 for couples therapy. Sessions are 45 minutes.
I also want to let you know that I take payment for the first session by credit card (over the phone) at the time of booking. The reason I do this is because therapy is a big step and many people get "cold feet" after they make the initial phone call. This is not unusual and very normal. It's not uncommon at all for a person to reach out to a therapist at a moment of urgency, and then, as soon as the feeling of urgency passes, to change their mind about the whole thing. This is one of the main reasons why so many people lose so much time before they actually follow through on getting the help they need. It's just more comfortable to try to fix things ourselves and it's scary and sometimes also embarrassing to get help. It's certainly a very vulnerable feeling to have to go see a therapist, and some people have also had negative experiences in the past which makes it hard to want to try therapy again.
One way I've found to help people make the commitment to follow through on coming to the therapy session, even if there are feelings of ambivalence, is to just take payment at the time of scheduling the first appointment. It just makes the follow through easier. Many people also like knowing that the session has already been paid for when they come in for the first session. Once you do come in for your session, we can certainly talk about any fears or doubts you have, and I will do my best to help you work them through...but at least you will have shown up!!
1. Which issues are you looking to work on in therapy?
Anxiety or Panic Attacks
Relationship issues/dating or premarital
Dealing with a difficult family member
2. What have you already tried to solve this problem?
Cognitive Behavioral Therapy
Self-help (reading articles online, self-help books, talking to friends etc)
3. What is your reason for seeking therapy right now?
Your doctor or a family member recommended it
Your symptoms are getting worse
You experienced a recent trigger, stressor, or crisis
It's something you've wanted to do for a while and the time feels right now
You want to be proactive about making sure your relationship is healthy
Recent infidelity issues
Single and worried about dating issues or your ability to be healthy in a relationship
Trauma and/or trust issues are getting in your way
You're tired of living a certain way and really want to experience a change
4. What barriers to following through on therapy apply to you right now:
Unsupportive Family Member
Unpredictable schedule/travel for work
Fear of change
Tendency to self-sabotage
Fear of trusting a therapist
Previous negative experiences with therapy
Your partner is not really on board
You are experiencing current trauma in the present so it will be hard to heal
You are in an abusive relationship
5. What costs will there be to not solving this problem at this time?
Relationship may break up
You will always wonder if your relationship could have been saved
You may lose your job
You may make a wrong decision about something major in your life
You will continue to suffer when maybe you could have gotten help
A small problem may become a much bigger one
You may not be able to date or get married
You will have to avoid activities that are important to you because of anxiety
You may hurt yourself
People in your life are going to suffer
6. What qualities in a therapist are most important to you at this time?
Your therapist is warm and nurturing
Your therapist is not afraid to push you
Your therapist respects your space
Your therapist gives a lot of feedback
Your therapist mostly listens
Your therapist gives concrete advice about what you should do
Your therapist helps you make connections you hadn't thought about
Your therapist helps you get more in touch with your thoughts and feelings
Your therapist genuinely cares about you
Your therapist is very formal
7. What is your desired result or transformation?
Waking up in the morning knowing you aren't going to have panic attacks
Feeling very comfortable, relaxed, and confident in social situations
Finding the right person to marry
Feeling really good about the communication in your relationship
Knowing whether you should stay or leave after an affair
Being able to open up more in relationships
Feeling more successful in your life
Learning how to trust (even if you're scared)
Being able to sleep well at night
Learning how to be less controlling
Feeling brave enough to get out of a toxic relationship
Becoming more accepting of yourself and others
No longer obssessing
Feeling confident about your decisions
Knowing you have a safe place to talk when needed
8. Any additional comments or questions about your answers above (or in general) before we speak?
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service