Before completing this "Consultation Form," you are encouraged to visit our website @ theliberatedself.org, so you could fully understand the intention and mission of our private practice.

The information being collected in this "Consultation Form" is intended to collect some basic information about you, the potential client of The Liberated Self Therapeutic Services, LLC, as a way to determine whether or not we are able to offer you the type of mental health services you are seeking.

Whenever you are seeking psychotherapy, it's important that you meet with a therapist, who can fully support you with working through your presenting challenges and therapeutic goals. This will ensure that you get the most value out of your therapeutic experience.

This “Consultation Form” will take approximately 10-15 minutes to complete. The information you enter will automatically be saved, in case you are interrupted or need to take a break. Once your "Consultation Form" is completed, you will be contacted, via email, within several business days, informing you of next steps.  

If there's a determination that we could offer the type of mental health services you are seeking, you will be emailed a link (via Alma or Headway), requesting your insurance information. Once your insurance information has been verified, you will then receive an email with your Intake Appointment, which will be based on your (and our) availability options, listed towards the end of this "Consultation Form." In this follow up email, you will also receive a link to our "Intake Form" and attached documents to sign and date (to be scanned and uploaded) to your "Intake Form."

The information included in this "Consultation Form" is considered confidential and is protected under HIPAA, a federal law that protects client health information. The Liberated Self Therapeutic Services, LLC has signed a Business Associate Addendum (BAA), under Google Workspace, and has taken all appropriate steps to ensure HIPAA compliance. The information in this “Consultation Form” cannot be shared with a third party, without your written consent; however, if you are threatening to hurt yourself or someone else, or if you report child or elderly abuse, your information, as required by law, will be shared with the appropriate authorities, to ensure your safety and the safety of all parties involved.

Notice: If you are CURRENTLY dealing with an emergency or mental health crisis, please DO NOT complete this "Consultation Form." Please EXIT this form and dial 911 or call the National Suicide Prevention Lifeline @ 988 or text "NAMI" to 741741 for support. You are also encouraged to reach out to a person you know and trust for additional support.