Shadow Work Psychotherapy | SimplePractice

Your info

First name

Last name

Phone

Date of birth

Gender

Who is this for?

Myself A couple A child or teenager Someone else

Reason for care

In your own words, what's bringing you here right now?

Let me know what you would like to work on, what's bothering you, or anything else that you think is helpful for me to know.

Limited to 600 characters

Is there a particular type of therapy or approach you're looking for?

Limited to 600 characters

Which services are you interested in?

Therapy Comprehensive Diagnostic Evaluation Both (Evaluation + Therapy) I'm not sure

Administrative

How did you find the practice?

Billing & Payment

How would you like to pay for sessions?

Sydney Carter, LPC: Individual therapy $175 · Initial intake $210 · Comprehensive Diagnostic Evaluation $1,200 (Accepts out-of-network benefits) | Kaitlyn Miles, Graduate Intern: Individual therapy $75 · Initial intake $120 (Private pay only) | Credit and debit cards, HSA, and FSA accepted. Payment plans are available for the diagnostic evaluation.

Self-pay Insurance (out-of-network) Unsure, would like to discuss options

Client Preferences

How would you prefer us to reach out?

Text message Email

Do you have a preference in a therapist?

We match clients to clinicians based on clinical need, specialization, and availability. If you have a preference, we will take it into account, and if you are not sure, we will make a recommendation after we talk.

Sydney Carter, LPC Kaitlyn Miles, Graduate Intern No preference, I would like your recommendation

How often can you attend?

I schedule clients at recurring times, so you have a consistent time each week.

Weekly Every other week I'm not sure N/A - Evaluation only

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.