Consultation Form

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"What is your wish for feeling better in mind and body"

Consultation Form

"Before you complete this consultation form please read
the Home Page and/or Therapist page to ensure that I am the right therapist for you
and hold experience in the approaches and problems you are seeking help for."

Connecting for a Consultation ~ Tell Me a Bit About You and Your Hopes for Therapy

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Phone Number *

I am seeking therapy support for *

Anxiety Depression Binge Eating or Emotional Eating Trauma (PTSD) Trauma (CPTSD) Personal Relationships Another problem or area I wish to grow in

History *

Do you have a formal mental health diagnosis Are you taking medications at this time Do you use alcohol/ substances to cope with negative feelings Do you use exercise/ shopping/ technology/ pornography to cope with emotions Do you have a history of dieting Have you used dieting to numb, gain control, belong Have you survived a traumatic event Have you survived family abuse, addiction, estrangement

If you checked Another Problem/Wish, please share *

Have you completed counselling before *

How old were you and was this a positive experience?

Age/Date of Birth *

Day/Month/Year

Relationship/Living Status *

Please briefly describe your your current living/relationship experience?

Current Coping Skills *

What helps you to cope with stress/struggles in life, and/or calm uncomfortable emotions? Supports, resources, family/pets, yoga, art...?

Preferred Pronouns *

If it feels safe, can you share your hopes and goals for therapy and working with me. What will life feel like/look like when you accomplish these goals? *

Do you have any questions, or is there anything else you want me to know? *

Submit

"Thank you for sharing your hopes, goals, and history with me. I look forward to connecting with you soon, 1-to-3 days."
Michele

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