Inquiry Form

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Inquiry Form

Thanks for reaching out!

Please fill out this form to help determine availability and to help me provide appropriate referrals if necessary. I make every effort to respond within 3-5 business days.

*Please note that I do not have availability for new clients at this time.*

Email *

Name: *

Phone number: *

How would you like to receive a response? Check your preference(s). (By checking a box, you give permission for receiving that form of communication.)

Text Message

Other:

For whom are you seeking counseling services? (Please note that I work individually with adults; I am unable to accommodate requests for couples, family, or children's counseling at this time.) *

For myself

Other:

Required

What is your age?

What are you hoping to address in counseling? (Please be as specific as possible.) *

Who recommended counseling? *

Myself

Family member or friend

Another mental health provider

Doctor or medical professional

Internet or social media content about therapy or mental health

Other:

How did you hear about Undivided Soul Counseling? *

Website (Google/Web search)

Word of mouth (friend, family member, co-worker, etc.)

Another professional

Insurance directory

Therapy Den

ISSTD

EMDRIA

Being Seen

Open Path

Other:

How would your sessions be covered? Check any that apply. *

Husky / Medicaid / State insurance

Anthem Blue Cross Blue Shield

Optum / United / Connecticare

Cigna / Evernorth

Beacon Health Options / Value Options / Carelon

Other insurance: will submit for out-of-network reimbursement (session fee $150 due at time of service)

Self-pay by credit card or check (session fee $150)

I have financial hardship and would like to inquire about Open Path sliding scale program (see website for details)

Other:

Required

What is your scheduling availability? *

Flexible (morning, afternoon, or evenings on most days)

Weekday mornings (9-12)

Weekday afternoons (12-4)

Weekday evenings (4-6)

Required

What is your preference for sessions?

Telehealth only (I have the required technology, Internet connect, and privacy for video sessions)

In-Person in Waterbury office

Mix of in-person and telehealth

No preference / any available

Clear selection

If I am unavailable to schedule with you, would you like to be provided with information about other possible providers? *

Yes

Other:

Send me a copy of my responses.

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