Hello! The purpose of this form is to find out if Therapy with Scarlett is a good fit for you. Please either fill it out on this page or download and complete it then email it to info@therapywithscarlett.com. I will get back to you within seven days.

If I feel that Therapy with Scarlett would be a good match for your needs, the next step will be a free 30-minute consultation. If I feel that Therapy with Scarlett is not best suited to meet your needs, I will do my best to respond with referrals to some options that may be a better fit.

Hours: For the initial period of business launching, therapy sessions will take place during weekday evenings and weekends. I hope to swiftly transition to having a wider range of operating hours.

Name

First Name

Last Name

Pronouns

Date of Birth

This practice only works with those who are at least 18 years of age.

Phone Number

(###)

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####

Do you prefer to communicate via email or text?

Address

Will you be using insurance to pay for therapy?

Please refer to the Insurance and Pricing page for more information.

If so, what is the name of your insurance?

Please tell me why you are seeking therapy at this time.

Have you previously received or do you currently identify with any sort of mental health diagnoses? If so, what diagnoses and do you feel they fit?

Are you taking any medications for mental health at this time? If so, what medications and how do you feel about them?

Are you concerned at all about your relationship with substances? If so, are you currently seeking support for these concerns?

Please note that I do not specialize in recovery. I am happy to support any work you may be doing but will refer you elsewhere if that is a primary reason you’re seeking therapy at this time.

Do you have access to reliable wifi, a smart phone, and a place to privately meet via telehealth?

Please read and agree to my Acute Need Disclaimer, below.

If you are currently having serious thoughts of ending your life or have had serious suicidal thoughts or made attempts in the last 6 months, I am not able to begin a therapeutic relationship at this time. My belief is that acute needs are best addressed by services able to provide more support than is available through a small private practice. If you’re in need of urgent care, please go to your local emergency room or call 988.

I have read and I understand the Acute Need Disclaimer.

How did you find out about Therapy with Scarlett?