Name
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First Name
Last Name
Child's First and Last Name (if child is the client)
(Child must be at least 13 years old)
First Name
Last Name
Date of Birth
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Phone
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(###)
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Email
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What state do you currently live in?
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I am only able to provide services for clients who are located in Missouri or Kansas.
What service are you interested in?
What type of therapy is best for you?
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What brings you to therapy?
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What goals do you have for yourself?
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Do you currently have any medical diagnoses? If so, what are they?
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Please include medication, if applicable.
What is your desired frequency for sessions?
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I do not currently take new clients who wish to be seen less frequently than every-other week. After we work together for some time, we may decrease your frequency to an "as-needed" or "monthly maintenance" frequency.
What is your preferred day and time for sessions?
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Please indicate any available times for sessions below.
**Appointments are scheduled on the hour, with the last appointment of the day starting at 3:00 PM.
The following information is a brief overview of my therapeutic approach:
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We will dive into your past relationships and experiences to gain insight into your current patterns. If you prefer not to explore your past, I may not be the right therapist for you.
Our focus will be on emotional processing by helping you identify, understand, and feel your emotions. Multiple therapy modalities may be used to meet you where you are at. If you do not wish to concentrate on your emotions, I may not be the right therapist for you.
We will work collaboratively. While I bring mental health expertise, you are the expert on your life, guiding our understanding of your experiences. You will have control in our sessions, deciding each week what to focus on.
We will embark on a long-term journey of exploration and healing. While we will address short-term stressors, this process is not a quick fix; it will take time.
Do you have any questions or concerns regarding my approach?
The following information explains some of my policies regarding payment:
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My rate is $150 for a 55-minute individual session. This is the private pay fee.
I do accept the following insurances: Aetna, BCBS of KC, Cigna, and Optum (UHC) - most plans are accepted. Insurance fees are different for each plan. It is your responsibility as the client to be aware of your insurance coverage and payment amounts.
I do require all clients to have a card on file in the case of late cancellations and or no shows. Late cancellations or no shows are charged the full private pay fee. If you are using insurance, this fee is not covered by insurance.
More detailed information is in my policies.
Do you have any questions or concerns regarding payment?
If you are using insurance, please select your provider.
I accept most insurance plans; however, there are some with which I am not in-network. To ensure coverage, eligibility checks are conducted prior to scheduling appointments. Please note that I am unable to accept Medicare or Medicaid at this time.
I understand that I will be responsible for the entire session fee if I cancel less than 24 hours prior to the scheduled session or if I am a No-Show to a scheduled appointment. Sessions are considered a "No-Show" if client is 10 minutes or more late.
Additional information you feel I should know: