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Name of Prospective Client *

First Name

Last Name

Name of Person Completing Form (*if different from prospective client information above*)

First Name

Last Name

Phone *

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Preferred Pronouns (Optional)

She/Her

He/Him

They/Them

Something Else

Will you be living or residing in California at the time of your therapy services? *

I am licensed in the state of California and located in San Jose, CA therefore I can provide virtual therapy to ALL California residents but only to California residents and I can provide in person therapy in San Jose, CA. **If you live or reside outside of CA at the time of therapy, I will not be able to work with you**

Yes

No

Who are you seeking therapy for? *

Myself

A Loved One

Interested in Family Therapy

What is the age of the prospective client? *

I specialize in working with folx 14 years or older. If you are looking for therapy for someone younger than 14, I would be happy to provide referrals.

Adult (18 years of age or older)

Minor (17 years of age or younger)

Do you prefer sessions be virtual, in person in San Jose, CA or a combination of both? *

Virtual

In Person

Combination

Are you available to meet for ongoing sessions between the hours of 9am-5pm on Mondays, Tuesdays, Thursdays, 2-7pm on Wednesdays or 9am-2pm on Fridays?? *

**The only evening availability I have is limited to Wednesday nights and I do not currently have any weekend availability, if you need times outside what has been specified above, I will not be the right provider for you.

Yes

No

How often are you looking to have sessions? *

For new clients, I require weekly or every 2 week meeting frequency to start. Once clients are established, there is flexibility to move to a different meeting schedule as needed. *This is in place in my practice to support consistency of care when starting out as there’s often a lot to accomplish for you to feel therapy is as helpful as it could be.

Weekly

Every Other Week

I'm not sure what I need

Please keep in mind I am not in network with any insurance providers. Although I am private pay, some insurance providers will cover out of network services and reimburse. My rates are $250/50 min individual therapy sessions. For family therapy I offer 2 session structures $275/50 min or $315/90min. Are these fees within your budget for out-of-pocket cost for therapy? *

I can run a free out of network insurance eligibility check through Thrizer to see if you are eligible for reduced copayment and reimbursement.

Yes, I can afford this fee fully out of pocket.

No, I cannot afford this fee fully out of pocket.

This may be affordable with use of out of network benefits. I’d like to check my out of network benefits eligibility during our consultation call.