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Thanks for taking this next step! I have a few quick questions...

Please complete this form for yourself only (not on behalf of someone else).

Personal Info

First Name

Last Name

Pronouns

Contact Info

Mobile Phone

How did you hear about me?

A friend/loved one told me about you

Directly referred by a health professional

We worked together somewhere else

Online search led me here

Map search or walked by

LLM like Chat GPT, etc.

Other

More specifically who/where?

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A few more questions

What are you looking for?

How would you like to begin?

Please tell me about your situation and what you'd like to do:

What inspired you to choose the work that I specifically offer?

Your privacy

My third-party booking software, Noterro, is HIPAA compliant and securely protects your information. I am professionally committed to your privacy. Our relationship is confidential, including information about you and what happens in a session, unless I have your written and signed permission to discuss your case or if I'm required by law to share information. Clients who work well with me are happy to add their credit/debit card to their appointment profile, and most clients choose to use this saved card as their regular form of payment.

Additional context

Your primary focus?

Secondary focus?

Would you like to mention anything else before we talk? (What days and times work best for you, specific limitations, hearing problems, requests, precautions, accessibility, anything you'd like me to know ahead of time)

Thank you for providing context :)

Upon booking your first in-person session, you’ll also receive direct links to my complete practice policies, covid policies, and cancel/reschedule policies so you can get a detailed sense of how I run my practice.

Prospective New Client Survey 2026

Thanks for taking this next step! I have a few quick questions...

Please complete this form for yourself only (not on behalf of someone else).

What are you looking for?

Your privacy

Thank you for providing context :)

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