Therapy and Coaching Inquiry Form
Welcome! I am glad you made it this far. If you have 5 minutes, I would like to get a little bit of information from you so that I can address your counseling needs and goals during a follow-up conversation scheduled at your convenience. After you click "SUBMIT" at the bottom of this page, you will receive a message with instructions on how to log in to my secure client portal to see my calendar and schedule your free consultation.

None of the information provided will be shared with anyone outside of Moxie LCSW Corp. Thank you for reaching out. -Jennifer Hampton, LCSW CA Lic 82213, TX Lic. 35678, Phone: (707)690-0745

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Name *
Email *
Phone Number *
Please select the main types of Psychotherapy or Coaching Services you are seeking. *
If you are seeking therapy for someone besides you or in addition to you, please provide their first name(s) and age(s) if they are a minor.
What issues need to be addressed right now? *
Tell me a little more about your current needs and goals.
What type of work (or education) are you currently involved in, including stay-at-home caregiver?
I see clients online and in-person from 9am-2pm, Monday-Thursday, and one weekday afternoon/evening or weekend day each week. At times, I have additional availability, but this is not guaranteed on a weekly basis so I don't post it on my online schedule. Reach out by email or text for inquiries to meet outside of hours posted online. Also, I offer free phone consultations for prospective clients between 2pm-3pm PT, M-Th, so please call me if you want to chat before scheduling a session. 
Please check when you are available for appointments. *
Best days/times for me to contact you for a 20 minute FREE phone consultation to help assist you in determining if I am a good fit for your needs: *
If I can't reach you, is it okay if I... *
Preferred Location to receive support (Note: factors outside of my control might impact our ability to meet in person.)
Have you ever seen a counselor or coach before? *
What qualities are you looking for in a therapist or coach?
What factor(s) most impact your choice of therapist or coach?
Any other details or information you would like to share so that I may better assist you?
How did you find out about Moxie?
Estimating your Cost for Counseling
Here is some information on how I set my fees, receive payment, etc.
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