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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Email *
Phone number
First name *
Last name *
Pronouns
Date of birth *
MM
/
DD
/
YYYY
City & State where you live *
If you were referred to me by someone, please share
Please 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 styles you think would be a good fit for you
Any disability accommodations that you need?
How will you be paying for therapy? *
(Unfortunately, all of my spots for sliding scale are full at this time)
*For more information about paying for therapy out of pocket and using out of network insurance benefits:
Please list all days and times (Mon-Fri) that you are typically available for regular therapy sessions *
How soon are you looking to start therapy? *
How would you prefer to meet? *
(In person sessions available on Wednesdays, Thursdays, and every other Monday; virtual sessions available any day)
Anything else you would like me to know
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