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Email *

Full Name *

Phone Number *

How did you find me? *

Psychology Today

Black Female Therapists

Therapy for Black Girls

Online Counseling

Therapy Den

Alma

EMDRIA

Google

Social Media

Family/ Friend

Other:

I am seeking therapy for *

Individual therapy for an adult

Couples therapy

Other:

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Provide brief information about what you would like help with: *

Please identify some times that may be a good time for us to speak in the next two weeks. It is best to identify a few times to reduce the "back and forth". The consults typically take 15-20 minutes. *

Monday

Tuesday

Wednesday

Thursday

Friday

Morning

Afternoon

Evening

Any thing in particular that I should keep in mind when scheduling our consultation?

Although I provide teletherapy, the laws for MFTs require that clinicians be licensed in the state they provide services. I am licensed in California and Texas. All of my clients must be in California or Texas for my services. I just wanted to be clear on those limitations. *

I am located in California.

I am located in Texas.

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Please check off all that apply. *

I understand that I will be contacted via email for my consultation and consent to this contact.

I have a private email account and understand that this is required to be registered as a telehealth client for this clinician.

I understand that this clinician uses HIPAA secure platforms for communication (Simple Practice, Google Suite, and Ivy Pay) and am willing to use these platforms.

I have a private space that is free from distractions that I can use to meet for telehealth sessions including this consultation.

I understand that this consultation does not automatically make me a client of this clinician.

I plan to use insurance for my services. I understand that this requires a mental health diagnosis by clinician and understand that insurance companies can request to review documentation about my services as well as limit the duration and/or frequency of my services.

I understand that this clinician uses a billing company (Alma) to complete courtesy insurance verification and collect co-payments. I also understand that verification, eligibility, or benefit information is not a guarantee of payment. Eligibility of services covered will be determined by clinician during initial session and by insurance provider once a claim is received.

None of the above.

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I encourage you to read through the FAQ prior to our consultation: https://www.amplifyconnectiontherapy.com/faq.

You may still have some questions that you'd like answered prior to meeting. Please share here so I can include them in my response email:

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