Contact Information
Please fill in the following contact form to be contacted for a phone consultation. 
IMPORTANT: Please be sure to check your email and junk folder. Allow 72 business hours for me to receive your info and contact you back. Note: vacations and holidays may delay my response.
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Email *
First and Last Name of Client/Parent or Guardian of Client *
How often are you looking to meet? Note: I recommend weekly or bi-weekly to start.  *
State of Residence of Client/Parent or Guardian of Client *
Phone Number *
Email You Check Regularly *
First and Last Name of Child Client (If applicable, otherwise type "N/A") *
I will need permission from all custodial parents to consent for therapy. Are you able to provide this? (If this does not apply, check "N/A.") *
Client's Age *
Pronouns of Client *
Required
How did you hear about me? *
Word of Mouth Referral *
What timeframe are you looking to begin therapy. *
Preferred Times to Meet (within my business hours: W 7-9pm (virtual), R 3-8pm (virtual), and F 10-6pm (office, virtual available)) *
Would you like to meet virtually or in person? (Note: The virtual option is for Kansas adult residents only. At this time, kids must come in person.) *
Check "yes" that you understand that I am private pay only and I do not accept insurance. *
Briefly describe the client's therapy needs here. What led you to seek therapy now? What are your goals? *
Has the client been in therapy before? If yes, when? *
Does the client have any mental health diagnoses? If yes, what? *
Is the client seeing a psychiatrist? Taking medication? If so, which ones? *
Any suicidal or homicidal thoughts? If so, how long ago? Please note: I do not review this form instantaneously, and thus will not see this right away. If you are in crisis, please seek help from emergency services, contact the National Suicide Prevention Lifeline at 988, or text the crisis text line, "HOME" to 741741. *
Any prior psychiatric hospitalizations? If yes, when? *
Any hallucinations or delusions? If yes, what/when/frequency? *
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