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Application for a Free 15 minute Phone or Video Consultation

Thank you for your interest in beginning your therapy or coaching journey with me! Your time is important to me, so please fill out this form so that I can confirm that you will be eligible for counseling with me before we schedule our consultation. Please note that I am licensed in the state of Florida, which means that I cannot see clients who are primarily residing in other US states due to US state licensing laws and regulations. However, I am available to take on clients in most international countries. If we determine that counseling with me is not feasible, you can always check out my self paced online course as a second option for learning ACT on your own for the price of one therapy session.

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Disclaimer

The information on this form will be sent to a secure, HIPAA compliant storage for my review. I will use this information to determine if we can move forward with scheduling a consultation, and I will also use it to prepare for our chat together. Once we have completed our consult, the information that you have sent to me will be responsibly deleted and I will not use it to solicit services from you later should you choose not to move forward with therapy with me.

This form is not to be used in cases of crisis or emergency. If you are experiencing any suicidal or homicidal thoughts, please call the National Suicide Prevention Hotline at 1-800-273-8255, or your country's local emergency and crisis line.

Important Acknowledgment

By clicking "Submit", you are acknowledging that you are not currently in crisis or participating in or planning any harm or abuse of others, that you are not immediately entering into any formal mental health counseling with me by sending me this form, that you are in agreement in the secure and confidential electronic recording of the information in this form, and that all of the information that you have provided here is true and correct to the best of your knowledge.

Name *

First Name

Last Name

Email Address *

Where are you currently living? *

please include city and country

Are there any places that you travel to often, or that you anticipate traveling or moving to in the near future? If so, please list.

Do you struggle with any of the following?

Anxiety

Depression

Other Mood Disorder

Agoraphobia

Obsessive Compulsive Disorder

Addiction

Eating Disorder

Trauma

Grief

Stress

Struggling with adjusting to something

Feeling confused with who I am

Feeling confused with what I am doing with my life

Struggling to accomplish my goals

None of the above

Other

Have you ever been hospitalized for psychiatric reasons? *

Yes

Have you ever experienced suicidal or homicidal thoughts? *

Yes

Have you ever attempted suicide? *

Yes

Please use this space to provide me with any additional information that you feel is important for me to know.

By providing me with this information, you will save us some time to be better able to talk about more details in our scheduled consult.

Would you like your free consult to be by video or phone? *

Video

Phone

What is your US phone number?

I only need this is information if you are requesting a phone consultation. At this time, I can only do phone consultations for US phone numbers.

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Thank you!

Thank you for taking the time to fill out this form

I will be reviewing your answers to this form and reaching out to the email address that you provided within 1 business day. If I feel that you are a good fit for services, you will receive a link to schedule your free 15 minute consultation with me. I will also ask you for any information that I need from you in order to make the consultation happen.

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