Pre-Consultation Form
Please complete the questionnaire prior to scheduling services 
Name *
Address *
Phone number *
What kind of therapeutic support are you looking for with me?
*
 Do you currently have any thoughts to harm yourself or others?
*
Do you currently work with any other mental health providers?
*

If so, for what diagnosed condition?

*
 My 6 week payment option is a cash pay only option. Will this be agreeable to you?
*
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