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 *
First name *
Last name *
Pronouns
Phone number *
Date of birth *
MM
/
DD
/
YYYY
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)
*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?
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