Clinical Consultation interest form

Please fill out this form as thoroughly as you can. It will help in our work together. If you do not choose to answer any question, please write "Do not wish to answer."

Today's Date

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Name

First Name

Last Name

Phone

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Email Address

Pronoun

Drop down box

What is your private practice website?

http://

Years in Practice:

Current Fee you Charge your Patients/Clients:

Referred By:

What initially drew you to the field of psychotherapy?

How would you describe your theoretical orientation?

What are attributes of your work that currently feel frustrating, draining, or challenging?

Current location (City and Country):

What type of support are you seeking through consultation? What would you like to see change (expand, shift, etc.) in the way you practice?

License number and State(s) Licensed in

Year licensed

Clinical Consultation interest form

PsychoTherapy and sex therapy offered in California, Colorado and oregon.

Coaching, classes and workshops are offered globally

#sexology #depthpsychology #yogatherapy #psychedelicintegration #PSYCHEDELICAssistedTherapy #SexTHERAPY #EMDR