Free Consultation

Ahead of your free consultation, we ask that you please fill out the following Pre-Consultation Questionnaire. This will allow us to spend less time on general information, and get right to how we can help you.

Full Name*:

Age:

Date of Birth:

Phone Number:

Email*:

Location:

1. How did you hear about me?
GooglePsychology TodayOpen PathiTherapyReferred by Family Member or FriendReferred by a Healthcare ProviderOther

If you used Google, what search terms did you use?

If you were referred by a Healthcare Provider, who?

If you answered "Other," please elaborate:

2. Which services are you interested in?
Individual Therapy (exclusively online)LCSW supervisionImmigration Mental Health EvaluationOther

If you answered "Other," please elaborate:

3. I offer individual therapy and complete immigration mental health evaluations exclusively through a video telehealth platform. Do you feel comfortable learning new technologies? Are comfortable or have you used video chat platforms before?
Yes, absolutely!No.Maybe

If you answered "Maybe," please explain your comfort level.

4. Have you contacted your insurance and verified your behavioral health benefits specifically for telehealth psychotherapy?
YesNo (It is strongly encouraged that you contact your insurance if you plan to use your benefits.)

5. At this time, I am not in network with any insurance. I can provide a superbill (which would require me to provide mental health diagnosis) which you can submit to your insurance to try to get out of network benefits. Due to the fickleness of insurance, I cannot guarantee that your insurance will cover telehealth psychotherapy services. My rate is $170 unless you are a part of the Open Path Collective.
I want to pay out of pocket and do not want to use my insurance benefits.I have contacted my insurance and verified my benefits. I would like a superbill to submit to see if I get reimbursement.I have not contacted my insurance regarding behavioral benefits specifically for telehealth psychotherapy. Either way, I would like to start telehealth psychotherapy services with you regardless of my benefits.I have not verified if I have behavioral health benefits specifically for telehealth psychotherapy at this time. I'm unsure if I would like to move forward with therapy without knowing those benefits or without a superbillI am a part of Open Path Collective

6. Please, provide a brief description of why you would like to start therapy.

7. Have you been to therapy before? When was the last time you saw your former therapist? For how long did you see your therapist?
NoYes

If you answered "Yes," when was the last time you saw your former therapist, and for how long did you see your therapist?

8. If you were in therapy before, what were some of the goals that you worked on? Did you feel like you accomplish those goals? If not, why?

9. I typically recommend starting with weekly therapy and as we start accomplishing the goals that we have set up, tapering off from there. Are you comfortable with that?
YesNo