New Client Consultation Form

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Please provide the following details to schedule and prepare for your consultation. I'll be in touch within 24-48 hours to schedule a 20-minute phone call.

Full Name *

Email Address *

Phone Number *

Address *

Age *

What type of service are you interested in consulting about? *

1:1 Therapy - Massachusetts

1:1 Therapy - Pennsylvania

1:1 Therapy - Virginia

Emotional Wellness Yoga

Mentoring /Consultation for Therapists or Yoga Teachers

Corporate Welness Programs

Speaking Engagments

Other (Please specify below)

Please briefly describe the main goal or challenge you are experiencing. *

How did you hear about our services? *

Referral - Friend / Family / Mental Health Professional

Online Search Engine / Google

Social Media

Psychology Today / ZenCare

Previous Client

Other

Required

All services are private pay. A Superbill is available for therapy clients with out-of-network coverage. All other services are self-pay without a Superbill. *

I understand.

I do not understand and have questions.

I will need a Superbill for therapy services.

I am unsure if I have out-of-network benefits for therapy services.

Required

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