CONTIGO WELLNESS Healers/Practitioners Request for Mental Health Services
We are forming a of Latinx/BIPOC practitioners that can provide healing sessions to Latinx populations. This form must be completed by the individual seeking therapy. Please choose a Contigo Wellness Practitioner from the website site, and complete the following form to include the Contigo Wellness practitioner selected. That practitioner will follow-up with you to schedule a session.  We'll schedule a consult with you to discuss financial need.

Este formulario debe ser completado por la persona que busca terapia. Seleccione un practicante de este sitio web y complete el formulario para incluir al terapeuta. Ese terapeuta hará un seguimiento con usted para programar una sesión.
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Email *
Contigo Wellness
Name (First/Last)  Nombre (Primera/Ultimo/a) *
Pronouns (He/She/Ella)   (Pronombres: El, Ella, Ellos) *
What zip code are you located in?  (En que codigo Postal estas?) *
Phone number  (Numero de telefono) *
Email address  (Correo electronico) *
Name of selected Contigo Wellness Practitioner  (Nombre de la therapeuta en Contigo Wellness) *
Name of selected Contigo Wellness Practitioner (if previous choice not available) (Nombre de la therapeuta en Contigo Wellness si la primera opcion no esta disponible) *
Age (Anos) *
What is the best way for the Practitioner to schedule  a session with you? (La mejor manera de llegar a ti) *
Required
Why are you seeking therapy?  (Por que estas buscando terapia?) *
What type of service are you interested in? (Por que estas buscando servicio?) *
Anything else you would like us to know? (Algo mas que debamos saber?) *
When are you looking to start therapy?  (Cuando quieres empezar?) *
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Have you been in therapy before?  (Has estado en terapia antes?) *
Are you on medications?  (Esta tomando medicacion?) *
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