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What's bringing you to therapy right now? (Check all that apply)

Anxiety, worry, or panic Relationship difficulties or patterns People-pleasing or difficulty with boundaries Feeling overwhelmed, burnt out, or emotionally exhausted Past trauma or difficult childhood experiences Low self-worth, self-esteem, or identity concerns Attachment issues or insecure attachment patterns Life transitions (career, breakup, relocation, etc.) Depression (low mood, lack of motivation, hopelessness) Grief or loss

Are you also experiencing any of the following? (Check all that apply)

In your own words, what do you hope to get out of therapy?

Example: "I want to stop overthinking every text message" or "I want to set boundaries without feeling guilty"

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Have you been in therapy before?

If yes, what was helpful? What wasn't helpful?

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What kind of therapist are you looking for? (Check all that apply)

Direct and solution-focused Warm and supportive Someone who specializes in trauma Someone who understands attachment patterns Someone who will challenge me when needed Faith integration (Christian perspective, if I request it) Someone experienced working with women Someone who is collaborative and practical

How ready are you to actively work on making changes?

My approach is active and change-focused. If you're looking primarily for a listening ear without active skill-building, I may not be the best fit.

Are you currently experiencing thoughts of harming yourself or ending your life?

If you're having thoughts of suicide or self-harm: Thank you for being honest. I want to make sure you get the right level of support. If you're in immediate danger, please call 988 (Suicide & Crisis Lifeline) or go to your nearest emergency room.

Are you currently experiencing thoughts of harming others?

Are you currently working with a psychiatrist or taking psychiatric medication?

Have you been hospitalized for mental health or psychiatric reasons in the past 6 months?

Are you currently involved in any legal proceedings (custody evaluation, divorce proceedings requiring therapist testimony, court-ordered therapy, etc.)?

Note:** I do not provide forensic evaluations, court testimony, or court-ordered therapy. If you need therapy separate from legal proceedings, we can discuss whether I can support you.

If yes, please describe?

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Are you seeking therapy in connection with FMLA leave, short-term disability, or workplace documentation?

I provide these services only for established clients (minimum 4-6 sessions). I do not offer one-time consultations for paperwork completion. If you're looking solely for documentation without ongoing therapy, I can provide referrals to appropriate providers.

My standard rate is $185 per session. I offer 2-3 reduced-fee slots at $150 for clients experiencing genuine financial hardship (application required). Which of the following best describes your situation?

How did you hear about me?

If using insurance, which plan do you have?

Payment method

How do you plan to pay for therapy?

Is there anything else you'd like me to know?

This could include specific concerns, questions about my approach, or anything else that's important for me to know.

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Which state do you currently live in?

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