New Therapy Client Inquiry
Thank you for your interest in working with me! Please answer the following questions. Your answers will not be seen by anybody except me.
-Stefanie Dominik (she/her)
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Date of birth
City & state of residence
If you were referred to me by someone, please share
Briefly describe what brings you to therapy/what you're looking to work on
Please describe anything you're looking for in a therapist/any qualities or approaches that you're seeking out
How will you be paying for therapy?
(Unfortunately all of my spots for sliding scale are full at this time-please choose one of the following options)
I have Bluecross Blueshield PPO insurance
I am out of network and will be paying out of pocket ($190 for intake/assessment; $170 for all subsequent sessions) *See below*
*For more information about paying for therapy out of pocket and using out of network insurance benefits:
How would you prefer to meet?
(In person sessions available on Wednesdays and Thursdays; virtual sessions available any day)
Please list all days and times (Mon-Fri) that you are regularly available for therapy sessions.
Any disability accommodations that you may need in order to make therapy accessible?
Anything else that you'd like me to know about you?
Send me a copy of my responses.
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