Confidential

New Client Intake Form

This takes about ten minutes. There are no wrong answers, and you can share as much or as little as you are comfortable with. Everything you write is held in confidence and read only by me.

If you have not yet requested a time, you are welcome to schedule an appointment before or after completing this form, whichever is easier for you.

About You
How You Found Me
Your Session

What are you being seen for? *

Please mark one *

Share as much or as little as you're comfortable with. There are no wrong answers.

Primary areas you'd like to work on (select all that apply)

Have you sought counseling or coaching before?

Are you currently working with a counselor, coach or pastor?

What would be different? What would you feel, think, or do differently?

Session Fees & Sliding Scale

I believe financial hardship should never stand between you and healing. My standard rate is $120. Choose below to select a rate that honors your current season. No documentation is required, I trust you.

Select your session rate *

HSA accepted.

Would you like to discuss payment options?

A note on safety and wellness. Questions about safety, substance use, or thoughts of self-harm are discussed privately in our first session rather than through this form. If you are in immediate danger, please call 911. If you are in crisis, call or text 988 to reach the Suicide and Crisis Lifeline.

Questions before you submit?

I would be glad to talk anything through with you first. Call me or send a message, and I will get back to you personally.

Send me a message Schedule an Appointment

Or call (601) 528-2598.

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