Prescreening for Evaluation or Coaching
This form is initial information for Dr. Milliken. Submitting this does not guarantee and appointment. Please be aware Dr. Milliken:
1) Does not accept insurance for any of her services. Rather, she has a fixed cost schedule for services.
2) Has limited openings for coaching. Most clients continue for 6-12 months
3) Does not offer therapy services, preferring to work from a coaching model
4) Works primarily with adults for coaching
5) Uses a comprehensive diagnostic interview and does not offer psychoeducational testing.
If you are seeking a service that is not listed below, you may wan to seek an alternative provider
Kirsten Milliken, PhD, PCC
Name of Client
Name of Person Completing This Form
Client Date of Birth
I am looking for the following service
This is to address the following question/issue
Need for School Accomodations
I was referred by a treating provider
Has the client been previously diagnosed with any mental health disorder?
Please briefly describe the purpose of the appointment request and relevant background
Email to send schedule link
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