Shadow Work Psychotherapy | SimplePractice

Your info

First name

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Reason for care

What would you like to work on?

Please list any symptoms, goals, or other reasons that bring you in to therapy.

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Which services are you interested in?

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Individual Therapy Full Diagnostic Assessment

Administrative

How did you find us?

Billing & Payment

How would you prefer to pay for sessions?

We accept out-of-network insurance benefits and FSA/HSA cards.

Self-pay Insurance

Client Preferences

Preferred Clinician

Sydney Carter, LPC (Trauma/EMDR Therapist) Kaitlyn Miles, Graduate Counseling Intern (Private Pay, $75/session)

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.