Wellness Within: 15-Minute Consultation Form
Thank you for choosing Wellness Within, we are glad you're here. Please fill out the questions on this form completely, in order to be contacted for your consultation at no cost to you!
After the form is completed, you will be contacted in the next 24-48 hours to speak to one of our skilled clinicians. We are giving you the opportunity to speak to a licensed therapist for a limited time of 15 minutes. During this time, you may ask one question that you feel is important to you. Our clinician will listen and offer you support based on your individual needs. This will be your chance to meet a clinician and talk about online therapy. *Please note this call will be limited to your time slot and any information shared during the consultation is confidential.
First Name / Last Name
Date of birth?
Parent/Guardian Name (if client is a child/teen)
Please write one question of your choosing that our clinicians can help you with. Note: This question can be about online therapy or your own personal question. Judgement free!
Due to the recent Coronavirus outbreak, TeleHealth is now a temporary option to ensure your safety and well-being. What method of Teletherapy will work best for you?
Do you prefer a particular therapist?
Zenaida Ortega, LMHC
Jim Yelinek, LMHC
Alyssa Desroches, LICSW
Christina Danforth, LMHC
Type of insurance?
Wellness Within accepts the insurance plans below. Please indicate what insurance plan you have to ensure we may begin treatment after your consultation.
Health New England
United Behavioral Health/United Health Care/Optum
Out of Network-Aetna or Cigna (must have Out of Network benefits and deductible may apply)
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This form was created inside of Wellness Within, LLC.