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First Name
Last Name
Age
Email
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Location (please note I can only see humans for therapy who currently reside in New Jersey)
Please share a brief description of why you are seeking therapy and your most pressing concerns & symptoms that you would like to explore in sessions?
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What are your top 3-5 goals?
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What do you believe has gotten in the way of you accomplishing / addressing those goals previously?
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Describe any personal growth work or practices you are currently engaged in.
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My approach integrates psychotherapy, holistic wellness, eastern philosophy, meditation practices, somatic psychology, and mindfulness, focusing on deep personal growth across mind, body and soul. How does this resonate with what you’re looking for?
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What are you looking for in our one-on-one sessions? (e.g., support, accountability, deep personal work)
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Were you referred to me by someone? If so, whom?
If you were with a previous practitioner, what worked and what didn’t?
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In therapy, we often speak of the importance of clients being both ready and willing to embark on the therapeutic journey. Do you feel that you are both willing and ready for therapy? If so, please briefly share why.
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What days and times typically work best for your schedule? Please provide a few options. *Please note I only see clients who are willing to commit to weekly sessions.
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Do you have a preference for in-person or Telehealth counseling? I am only seeing clients virtually at this time
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Do you plan on using insurance or self pay? Please list your insurance
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If my group practice does not take your insurance, are you open to doing self pay?
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If using self pay are you in need of sliding scale? How much can you afford at this time?
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If there is anything else that you think would be helpful for me to know about you or if you have any particular concerns, please share here
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