Therapy Consultation Form
Please take a moment to complete this form. The following questions are used to ensure appropriate service.
**All therapy services are virtual unless noted otherwise.**
Are you a Florida resident?
Phone Number: (By providing your phone number you authorize contact for the purpose of receiving services.)
Email: (By providing your email you authorize contact for the purpose of receiving services.)
Select any service you wish to receive
Clinical Supervision (For Registered Florida MH & MFT Interns Only)
1 on 1 Wellness Coaching
Wellness Party (Intimate therapist led discussions on self-care, marriage, parenting, and more.)
Select the therapy service are you presently seeking?
What issue(s) would you like to address with therapy?
Have you attended therapy before? If yes briefly explain
Are you currently taking/prescribed psychotropic medication(s)? If yes, please list
Are you currently suicidal? National Suicide Prevention Helpline (Available 24/7) 1-800-273-8255.
Yes, Thoughts only
Yes, Thoughts and plan
Yes, I have Attempted
Do you have a history of self harm or suicidal ideations? If yes, please explain. (If no, write N/A)
Are you currently using substances or do you have a history of substance abuse? If Yes, please explain
We do not accept health insurance. Documentation (Superbill) is available upon request should you wish to submit expenses to your insurance provider for reimbursement. Services could be considered as out-of-network benefits by your insurance provider. **Please check you insurance coverage carefully.
Yes, I have read and acknowledge the insurance policy.
Rates for therapy services are as follows: Individual-$120; Couples-$150; Family-$200. Please select a therapy service.
How did you find us
Therapy For Black Girls
DRK Beauty Healing
Please share appointment preferences.
Please list any additional questions below.
Thank You for taking the first steps in your wellness journey. You will be contacted with further information to receive services.
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