Phone Consult Questionnaire

This form helps us save time during our consultation by giving me a general sense of what you hope to gain from therapy. You will have the opportunity to discuss these questions more in-depth during our phone call.

Initials *

First

Last

Issues that you are struggling with (Check all that apply) *

Anxiety or social anxiety
LGBTQIA-related issues
Low self-esteem or self-worth
Highly-sensitive person
Identity exploration
Body image issues
Depression
Past bullying or emotional trauma
Relationship issues
Loneliness/isolation
Other

I work exclusively through a secure, convenient telehealth video platform. Are you open to telehealth sessions? *

Yes
No

I am an out-of-network provider for most insurances. I do not bill insurance directly, but I will work with you to provide receipts and help you determine your out-of-network coverage. *

I understand.

I work with residents in Illinois and Florida. Which state do you live in? *

Illinois
Florida