Respark Client Inquiry Form
Welcome to Respark, We're so glad you're here. Please fill out the information below to take the first steps toward working together. Next, we'll contact you to schedule your first appointment.
Best Contact Phone Number
May we leave a message at this number?
Yes, but please do not state the name of the agency or the purpose of the phone call.
How would you like to be contacted?
How did you hear about us?
Therapy for Black Girls
Melanin and Mental Health
Referred by Another Therapist
Referred by a medical doctor
If another clinician or friend referred you, may we have your permission to thank them for the referral?
What times are you available to come in for a weekly appointment?
Keeping in mind that sessions usually last about 50 minutes, select all that apply
This day doesn't work for me
This day doesn't work for me
Given that the appointment time is available, When would you like to come in for your first appointment?
Some of our clinicians offer sessions online. Please indicate here if you would like to request this option.
Yes! I would prefer to see my therapist online.
I would like to consider seeing my therapist online as a supplement to in-persons sessions.
I prefer only seeing my therapist in-person.
What type of therapy are you looking for?
Tell us about your ability to pay
Our services start at $125 per session for individual and $150 for couples. We do offer discounts on a limited basis. Additionally, Respark is currently offering service to those using their out of network benefits which means you can submit a receipt (called a superbill) to the insurance company receive reimbursement for out of pocket payments directly from them. You can call your insurance company to see if your plan has out of network beinfits. Please check with your provider to verify your benefits. We also accept health savings accounts and flexible savings accounts. If you’d like more information about options for payment, please mention it at the bottom of this form.
My ability to pay is:
Full Rate at $125.00 - $200 a session
I'd like to request a discount at $95.00 a session (Join the waitlist)
I need a lower fee referral. (Please contact YWCA, Capital Area Counseling or us for more options)
Please briefly describe what you would like to accomplish in therapy
Did you find a particular therapist on our website that you would prefer to work with? Please note with online sessions, you must have address of the state listed next to the Therapist.
Heather McPherson M.A., LPC-S, LMFT-S, CST (Austin, Denver or Online) $200/hr for couples, $150/hr individual
Jessica Congdon, M.A. LPC Intern (Austin or Online)
Kathryn Barksdale, M.A. LPC Intern (Austin or Online)
Emily Forsythe M.A. LPC (Online or in Austin quarterly)
Kara Nassour M.A., LPC Intern (Austin only)
Do you require any special accommodations?
I use a wheelchair
I need large print intake documents
Anything else you'd like us to know?
We appreciate your taking time to fill out this information. You should expect someone from Respark to contact you within the next two business days.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service