Referral & Consultation - Individual therapy 


Referral & Consultation Form for Individual Therapy

Thank you for considering my therapy services. Starting therapy can be a significant step, and I'm honored you're taking this initiative. I specialize in therapy for women, with a focus on anxiety, depression, parenting changes, relationship conflicts, stress, and perinatal mental health. My approach is individually tailored, integrating various methods to provide effective support.

To better understand your needs and determine if we're a good fit, please complete the form below. After receiving your information, I will contact you to schedule a complimentary 15-minute consultation call.

Please note, I offer telehealth services exclusively to residents of California.

Website: https://www.susanlowecounseling.com/ 

Psychology Today Profile: https://www.psychologytoday.com/profile/1165857 

Email *
Untitled Title
Today's date *
MM
/
DD
/
YYYY
Name  *
Email *
Phone number *
How did you learn about me?  *
If other, please tell us below

How do you prefer I contact you? 

*

Thank you for reaching out. Please share a little about what brings you to therapy. This will help me understand how I can best support you. Your information will be kept confidential.

What brings you to therapy? (Briefly describe your main concerns or challenges.)

What are your goals for therapy? (What do you hope to achieve or work on?)

*
I look forward to speaking wiht you.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Susan Lowe Counseling. Report Abuse