Relationship/Couples therapy Waiting List
This intake will be used to assess fit and your needs. Kenya's assistant will reach out to schedule a consultation once there is availability in Kenya's caseload. 
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Email *
Partner #1 First & Last Name & pronouns  *
Email *
Phone Number *
Partner #2 First & Last Name & pronouns *
Email *
Phone Number *
Partner #3 Name & pronouns (if applicable)
Email
Phone Number
What state do you live in? (Reminder: Kenya Crawford, LMHC is licensed in New York) *
What are you hoping to work on in therapy? *
Have you been to couples therapy before?  *
Required
What led you to reach out to me specifically?  *
How would you like to pay for sessions? 
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Rates are based on an anti-oppressive rate structure. Please answer the following questions to determine your rate structure. (Adapted from the Anti-Oppression resource & training alliance)

1. Are you and your family homeowners or landowners? (This question does not apply to those who are Native or Indigenous)

2. Have you attended private education institutions or do you have an advanced degree?

3. Are you able to make minimum payments on bills or credit cards?

4. Have you been able to easily access and afford health insurance for yourself and your family members?

5. Do you have zero to no debt and/or do you have disposable income?

6. Do you have a safety net composed of “financially stable” or wealthy family and friends?

7. Do you have U.S. Citizenship?

8. Does your income only support you, and not other loved ones?

9. Have you or do you expect to inherit money or property?

10. Have you (or could you have attended college and/or graduate school?


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When are you available for sessions? (Between 1:00 pm - 5:00 pm Monday-Thursday)
Any additional information you'd like to provide? 
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