Intake & Consent Form
Before your first session with Karina Mirsky, MA, please fill out this form:
- Takes 3-4 MINUTES to complete
- Submit 48 HOURS before your 1ST appointment

*Please also whitelist:
Email *
First & Last Name - (feel free to add a nickname or the name you prefer to be addressed by) *
Preferred Pronoun (optional)
Clear selection
Phone *
Who were you referred by? *
I am seeking to work with Karina PRIMARILY for: *
I seek support PRIMARILY for: *
Are you currently being treated for or managing any significant physical or psychological health condition?
Are you taking any medications that might be useful for Karina to know about? (hormones, blood-pressure, antidepressants, sleeping pills, etc)
Is there anything else you would like Karina to know at this time? (optional)
What is your preferred method of payment? *
PAYMENT POLICIES: By checking the boxes below you are confirming that you understand and consent to policies for payments *
COACHING RELATIONSHIP AGREEMENT: By checking the boxes below you agree to enter into a coaching relationship with Karina: *
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