New Client Questionnaire

New Client Questionnaire
If you’re seeking an appointment with me for the first time, please complete the following form to the best of your ability. This makes it easier to connect, determine whether I’m an appropriate support for you, and arrange appointment logistics. Your information is kept confidential for my records only, and is sent directly to my e-mail once submitted. Sincere requests only please. Once you complete the form, click on "submit". Please be sure to fill in all the *required fields or it will not submit. Thank you.
Example format: Mar 14, 2021
How did you find out about my services? *
First & Last Name
(999) 999-9999
Please check your junk mail/spam for e-mails from me. Gmail often puts e-mails into junk mail. Hotmail addresses frequently bounce back. If at all possible, please use an alternative to Gmail and Hotmail, and add my e-mail address to your contacts to help ensure that you receive them.
Please indicate who this healing is for: *
Please note: 17 years of age and younger is a considered a child. If you are contacting me on behalf of another adult, such as a family member or friend, that individual will have to contact me directly.
If this session is for you, have you previously participated in any COUNSELING sessions that addressed your emotions, inner child or family of origin? *
Are you ready to move forward with healing this issue in your life? Please indicate: *
We will arrange a specific appointment by e-mail. For now, please indicate the different periods when you're generally available for a healing session. *
Appointments are available Monday to Thursday 10 a.m. to 6 p.m., and Friday 10 a.m. to 3 p.m. EST.
Appointments are available Monday to Thursday 10 a.m. to 6 p.m., and Friday 10 a.m. to 3 p.m. EST.