CONSULT FORM
By filling out this form, you have given me permission to make contact with you via the details provided for the referral of counseling services. For more information about the counseling practice go to www.groundinghearts.com/viergelyn
LEGAL FULL NAME
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First Name
LAST NAME
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
I have read your clinical focus and specialties and understand that you are a trauma psychotherapist and focus primarily on the impact of trauma. Is this the reason for counseling? More information here https://www.groundinghearts.com/clinical-focus
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YES
NO
Please explain your primary reason for seeking counseling services?
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Are there any current or future legal concerns ?
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YES
NO
Are you primarily seeking counseling for work-related or academic concerns?
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YES
NO
In the past 6-months, have you had in-patient hospitalization, Intensive Outpatient Program (IOP), Partial Hospital Program (PHP) or terminated a counseling relationship?
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YES
NO
Are you currently taking prescribed medication for a mental health condition?
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YES
NO
Office Hours: Tuesday and Wednesdays 10-7pm, and Fridays 10-2pm. Please indicate below if you have an availability preference
TUESDAYS (10-2, 4-7PM)
WEDNESDAYS (10-2, 4-7PM)
FRIDAYS (10-2PM)
From section above, what are the days/times you are available for sessions?
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What is your form of payment for counseling?
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BCBS
Private Pay
Are you currently meeting with a therapist (seeking adjunct therapy)
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YES
NO
This question is important. Do you foresee any future circumstances that may impact/interfere with attending counseling sessions? (For example, changes in work schedule, traveling more than 14 days, moving further away, childcare, medical procedures, legal proceedings) etc.
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YES
NO
Referral (agency, college/university, family/friend member, other)?
Submit
Should be Empty: