Consultation Questionnaire, Tiha Baker, LPCC
Thank you for reaching out to book a consultation! In order to ensure a good fit for the both of us, I'd like to ask a few questions. This will help me to get a better idea of your needs and how best I can serve you. 

Please take a moment to answer the questions below to the best of your ability. I will follow up with an email and link to my online calendar so you can schedule a free 15-minute consult.

I'm so glad that you reached out!

*If you are currently in crisis please go to your nearest emergency room OR call the National Suicide Prevention hotline at 800-273-8255 (24 hours).
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Email *
First and Last Name *
Pronouns *
Phone Number *
Are you interested in *
Briefly explain why you are seeking therapy at this time: *
My fee for therapy is $200/session, 50 minutes for individuals weekly. I only provide bi-weekly therapy after 12 to 16 weekly session. I can provide you with receipt called a 'super bill' to submit to your insurance if your plan qualifies for reimbursement of psychotherapy. I do have limited slots for lower fee therapy with a waitlist. What best describes your situation? *
If you answered "other" for your fee situation, please provide a short explanation. 
Please let me know if any of the following situations apply to you: *
How did you find me? (i.e. online search, website, referral)
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