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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