Journey to Self Pre-Consultation Survey                
Thank you so much for contacting us.   Please take a few minutes to answer the questions prior to our consultation session. This will help me understand your need as and determine if I will be able to assist. 
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Name *
Date of Birth *
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DD
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Phone number *
Email Address *
How did you find us?
Will you be self pay, using insurance or FSA/HSA?
 *
Which Insurance *
Seeking Services for  *
Required
What are your best hopes for participating in therapy services?
 *
Reason for Seeking Services *
Do you have reliable internet and a private, confidential place to talk during our virtual meetings? *
What are some symptoms you are currently experiencing? *
Have you been seen by a mental health professional before? If so, what was the reason for seeking services and dates you sought services with them?  *
When is your preferred availability to meet for services? (Preferred days and times) *
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