A Healing Place Pre-Consultation Form/ WAITLIST FORM

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Hi! Thank you for your interest in working with me! Please answer each question as completely and thoroughly as possible as answers will be used to assess if we are a good fit to begin working together.

Please be advised, if you do not completely answer the intake questions, you will not be able to begin working with me. If you have any questions or concerns about the process, please feel free to email me therapywithjuliann@gmail.com.

Once you complete this form, I will reach out to schedule a consultation call to further assess fit.

Email *

Please enter your first and last name: *

Please select your pronouns: *

She/her

They/them

He/him

Other:

Required

Please enter your cell phone number: *

Please review my New Client page on my website before continuing and check here to confirm that you have reviewed the following link: ahealingplace.me/#get-started *

I reviewed the Get Started Page

Required

Please select your state: *

Please check your insurance provider below:

(At this time I am unable to accept Medicaid plans. I do not accept the following Carelon plans: Emblem, NYSHIP, Wellsense, Unicare/Wellpoint, Humana)

If you have insurance, please enter your Member ID here: *

If you have insurance, please enter your Group ID here: *

If you selected Other, I am not able to accept your insurance. I would be considered an out of network provider for you. This means that you would be required to pay for your session up front ($200) and I can provide you with a Superbill to submit to your insurance for reimbursement. *

Please read my FAQs before continuing and check here to confirm that you have reviewed the following link: https://ahealingplace.me/#FAQs *

I reviewed the FAQs

Required

I only work with clients 18 years old and older. Are you at least 18 years of age or older? *

What's your date of birth (mm/dd/yyyy)? *

I currently see clients on Monday - Friday.

What is your availability during this timeframe? Check all that apply.

Monday Afternoon (2p, 3p)

Monday Evening (4p, 5p, 6p) WAITLIST

Tuesday Afternoon (12p, 2p, 3p)

Tuesday Evening (4p, 5p, 6p) WAITLIST

Wednesday Morning/Afternoon (10am, 11am, 12pm)

Thursday Morning (11a)

Thursday Afternoon (12p, 2p, 3p)

Friday Morning (10a, 11a)

Friday Afternoon (12p, 2p, 3p)

Required

What's bringing you to therapy at this time *

Anxiety, stress, or overwhelm

Relationship struggles (family, friends, or romantic)

Difficulty setting boundaries or meeting your own needs

Struggles with self-esteem, self-worth, or self-doubt

Repeating unhealthy patterns in life or relationships

Career or life transitions

Other:

Required

What are your goals for therapy *

To build self-trust and confidence

To explore and rewrite life narratives

To stop repeating unhealthy relational patterns

To process emotions and manage stress more effectively

To achieve symptom relief (anxiety, sadness, overwhelm)

Other:

Required

How would you describe how you generally feel in terms of relationships with others? *

Fear of being abandoned or not enough

Desire closeness but fear intimacy

Balanced and healthy

Desire independence, tend to suppress emotions and avoid intimacy

Not sure

Required

Have you attended therapy before? *

Are you open to exploring how your past experiences shape your current challenges?

What type of support are you looking for?

*

How would you describe your current coping mechanisms?
*

How do you feel about committing to weekly or bi-weekly sessions?
*

What qualities are most important to you in a therapist? *

Are you comfortable with virtual sessions?
*

Who is your emergency contact and what is their contact number? *

I am a licensed mental health counselor/licensed professional counselor in the states of New York ,Rhode Island, Massachusetts and New Jersey only. I can only work with clients who are physically in NY, RI, MA, or NJ. Please check here to specify that you understand this. *

I understand the statement above and I confirm that I can be in the state of NY, RI, MA or NJ when logging into sessions online.

Required

What is your address? Please enter your full residential address include city, state and zip code. This is used to verify your insurance coverage *

My fee is $200 per session. I meet with clients weekly or biweekly only. This means committing to a minimum of two sessions per month. That's a financial commitment of $400/month. Is this something that is feasible for you at this time? *

Yes

I have one of the insurances that you work with

If you answered no to the above question, please explain here: *

How much can you afford to pay per session on a biweekly basis? *

How did you hear about A Healing Place? *

Therapy For Black Girls

Psychology Today

Inclusive Therapists

Instagram

Headway

Alma

Other:

Do you feel ready to engage in therapy that balances emotional exploration with practical tools for change?
*

Is there anything you would like me to know? *

I understand that submitting this form does not guarantee acceptance as a client and that a follow-up consultation will determine fit. *

I Understand and consent to the above statement

Required

A copy of your responses will be emailed to the address you provided.

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