New Client Questionnaire

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If you are a new client seeking services, please answer the following questions and Alicia will respond within 1 week of receiving your answers.

Email *

What is your name? *

What is your phone number? *

Briefly describe the reason you are seeking therapy.

Are you interested in:
*

Individual therapy

Couples therapy

Both individual and couples therapy

Is the primary client seeking therapy over 18 years of age?
*

Yes

Are you seeking:
*

Telehealth

In-person

No preference

Please describe your availability for a 45-53 min session:
*

Daytime only 7a-4p M-TH

Evening only 4p or later M-TH

I'm flexible M-TH

If using insurance benefits to cover session costs, please provide your insurance carrier below:
*

Do you have a secondary insurance at this time?
*

Yes

Maybe

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