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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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Email
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Your answer
I'd love to know how you heard about me or Shades of Resilience Counseling?
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Referred by someone
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Email
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Phone Number
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Have you taken some time to review the Shades of Resilience Counseling website (i.e. Bio, Fees, FAQs)? www.shadesofresiliencecounseling.com
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Which service are you interested in?
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Individual Therapy
Mindfulness Teaching
Group Therapy
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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 (
limited availability).
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?
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Yes
No
In a few words, explain your reason(s) for seeking therapy. Why are you considering therapy now?
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Your answer
In a few words, describe what you hope to achieve from therapy?
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Your answer
Would you consider group therapy in the future?
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Maybe
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If you know, what are you looking for in a therapist?
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Do You have any initial questions or comments?
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Send me a copy of my responses.
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