Consultation Request Form
I'm looking forward to learning what's bringing you to therapy and discussing how I may be able to help you. To be respectful of your time please provide the information requested below. I will respond within 24 business hours of receiving this request. Thank you! ~Tracy
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I'd love to know how you heard about me or Shades of Resilience Counseling?
Referred by someone
D. O. B
Have you taken some time to review the Shades of Resilience Counseling website (i.e. Bio, Fees, FAQs)? www.shadesofresiliencecounseling.com
Which service are you interested in?
If you are in need of a reduced fee, please select the tier that would best fit your needs for weekly or bi-weekly sessions (
Tier 3: Intake $150/ each session $125
Tier 2: Intake $125/ each session $100
Tier 1: Intake $100 / each session $75
Is this the first time you've considered therapy?
In a few words, explain your reason(s) for seeking therapy. Why are you considering therapy now?
In a few words, describe what you hope to achieve from therapy?
Would you consider group therapy in the future?
If you know, what are you looking for in a therapist?
Do You have any initial questions or comments?
Send me a copy of my responses.
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