Therapy Consult Questionnaire

Thank you for taking this step with us. These questions help us learn more about your needs so we can connect you with the clinician best suited to support you. We'll review your responses and reach out within 24 business hours to schedule your intake appointment.

Legal First Name (for records/insurance)

Legal Last Name (for records/insurance)

If you go by a name that's different from your legal name, please share it here so we can address you correctly.

Street Address

Apt./Unit #

City

State

Zip Code

Email

Phone

Birthday

Month

Day

Year

We serve people from different walks of life who have at least one thing in common: they've learned to keep going while quietly carrying experiences that have taken a toll on their sense of self and well-being. Which of the following best describes you?

Student (Undergrad or graduate)

Healthcare Professional (Surgeon, physician, pharmacist, nurse, etc.)

Survivor of religious trauma or spiritual abuse

What brings you to therapy?

What would you like therapy to help you feel lighter, clearer, or more at peace about?

Over the past year, have you had thoughts of suicide or taken steps to harm yourself or end your life?

Yes

No

If you answer "yes," it does not affect your ability to receive care, it just gives us the insight to plan your care safely.

If yes, please tell us a bit more about when that was, what was happening for you around that time, and how you're doing now.

Have you been discharged from a psychiatric hospital or inpatient program in the past 12 months?

Yes

No

If yes, please share the facility name and your approximate admission or program start date.

Which day(s) do you have the most flexibility to meet for your first session?

This helps us explore which of our available appointments might work best for you. We'll reach out via email with a few options so you can select the one that best fits your schedule.

Do you prefer a certain time of day?

Morning

Afternoon

Evening

Flexible

Self-pay? You can skip the remaining questions and scroll down to the submit button to complete your form. Our out-of-pocket rate is $135 per session.

If you'll be using insurance to pay for sessions, please select the name of your carrier.

Anthem

Aetna

Blue Cross Blue Shield

Optum/United Healthcare

If the insurance company you have a plan with is not listed, we'd be happy to see you as a self-pay client for $135 per session.

If you plan to use insurance for your sessions, please upload a clear photo of the front of your insurance card. This helps us verify your benefits so we can confirm your co-pay and coverage details.

Please be sure to upload both sides of your insurance card so we can verify your insurance details.

Please upload a clear photo of the back of your insurance card. This side often includes important contact and plan details that help us during the verification process.

Please be sure to upload both sides of your insurance card so we can verify your insurance details.

Therapy Consultation Questionnaire