Seeking AHA Services

Seeking AHA Services

Submit this interest form to seek services with the Aspen Haus Associates, LLC team.
Contact Information

Please use your legal name.
Name*

First NameLast Name
What name do you go by? (nick name)
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Permission to Contact
I give AHA permission to use the following contact and leave messages.

EmailPhoneMailing Address
Who are you seeking services for?

MyselfMyself and another party (i.e., marital, family, etc.)My child (17 yrs or younger)My child (18 years or older)Another adult family memberOther
For those seeking services on behalf of another party:

If the other party is a minor, we can only fully explore potential services with the minor's guardian(s).

If the other party is an adult (18 years or older), we cannot make arrangements or discuss details of potential services with anyone other than the prospective adult client. The prospective adult client must contact our office directly to initiate any processes or services.

We can discuss general processes and provide basic information about Aspen Haus with any party that would like more information.
Please complete the remainder of the form for yourself or a party you are elligible to represent.
Previous & Other Professional Services
Previous Client?
Have you previously sought or received services from AHA or an Aspen Haus Associate?*

YesNo
If 'Yes', which clinician were you a previous client of?
Other Providers

It is important we have the following information.
Please list all current and previous MENTAL HEALTH PROVIDERS from the last 5 years. Indicate which are current if applies. (Type 'NA' if none.)*
Please list all current and previous MEDICAL PROVIDERS (MDs, PTs, etc.) from the last 5 years. Indicate which are current if applies. (Type 'NA' if none.)*
Please list all current and previous COACHES or OTHER HELPING PROFESSIONALS (Leadership, Life, Couples, etc.) from the last 5 years. Indicate which are current if applies. (Type 'NA' if none.)*
Are you a patient of Fire PT, Root PT & Wellness, Genesis PT & Wellness, or any other pelvic floor physical therapy providers?

YesNo
Referral?
Please tell us how you found our office?*
Who referred you to AHA? (Type 'NA' if none.)*
Which provider were you referred to and/or would prefer see? (Choose One)

No one specificJenna MountainKimberly GalindoAnna StubbsMallory OxendineRebecca FaggettAbdi PattenChelsey HoganEver TalamantesBirkley OliverAnjaly AntonyRachel HenningAny AHA ProviderNot listed
Reason for Seeking Services
I am interested in the following services (check as many as applies):*

Individual CounselingTrauma CounselingEye Movement Desensitization and Reprocessing (EMDR)Marriage or Couples CounselingPremarital CounselingSex TherapyFamily TherapyGrief CounselingGroup Coaching, Counseling, or Support GroupsConsultation & Evaluation (Non-clinical)Speaking & TrainingCoachingAdolescent (12-17)Child Therapy or Play Therapy (3-12 YO)EMDR IntensivesIASIS Micro Current NeurofeedbackOther
I am interested in working on the following issues or challenges THAT ARE CURRENTLY PRESENT IN MY LIFE, or ARE/HAVE-BEEN PRESENT IN MY CURRENT RELATIONSHIP (check as many as applies):*

Marital ChallengesAffair RecoverySexual IssuesIntimacy IssuesPast Wounds or TraumaChildhood AbuseFirst ResponderPTSDDomestic Violence or Partner AbuseSubstance Abuse or AddictionSexual Addiction or Compulsive IssuesPhobiasAnxiety and/or depressionSports PerformanceGrief or LossBereavementChronic Illness or PainBoundariesInfertilityPost-partum ChallengesOther
I am interested in working on the following issues or challenges THAT ARE A PART OF MY HISTORY BUT ARE NOT PRESENT IN MY LIFE AND/OR HAVE BEEN A PART OF MY CURRENT RELATIONSHIP (check as many as applies):*

Marital ChallengesAffair RecoverySexual IssuesIntimacy IssuesPast Wounds or TraumaChildhood AbuseFirst ResponderPTSDDomestic Violence or Partner AbuseSubstance Abuse or AddictionSexual Addiction or Compulsive IssuesPhobiasAnxiety and/or depressionSports PerformanceGrief or LossBereavementChronic Illness or PainBoundariesInfertilityPost-partum ChallengesOther
Please briefly describe reasons for seeking counseling based on the above choices.
Aspen Haus Associates Appointments/Phone Calls will be scheduled by appointment only.

If you are ever in a state of emergency, call 911 or go to the nearest emergency room for emergency services.

Emergency and immediate services are not services provided. The following local resources are alternative options for potential clients who find themselves needing higher levels of care:

EMERGENCY RESOURCES
- Dallas County MHMR 877-283-2121
- Tarrant County MHMR (817) 569-4300
- Collin County MHMR Lifepath Systems (Collin County MHMR) (972) 562-0190
- 24/7 Crisis Text Line Text “NAMI” to 741-741
- National Suicide Prevention Lifeline 1-800-273-TALK (8255) or 1-800-SUICIDE (1-800-784-2433)
- Parkland Hospital Psychiatric Emergency 214-590-8000
- SAMHSA's National Helpline. (800) 662-4357
- The Turning Point Rape Crisis Center Crisis Line 1-800-886-7273
- Dallas Area Rape Crisis Center (972)-641-7273
- Hope’s Door 24-Hr Hotline (Collin County) (972) 276-0057
- Family Place 24-Hr Crisis Line (Dallas County) (214) 941-1991
- Genesis Women’s Shelter Hotline (214) 946-4357
- Carrollton Springs 24 Hr Hotline (972) 885-3795
Do you have a preference on which provider you see or location?
Location Preference (Check all that apply)

Greater Dallas Area: Richardson, Texas (In Person/Online Services)Greater Fort Worth Area: Mansfield, Texas (In Person/Online Services)New Jersey (Counseling/Coaching Online Only)Other state/country (Coaching Only- We can do a lot of work in coaching.)Online Services (Preference)
Are you seeking bilingual services (Spanish)?

YesNo
Select the clinician that is your top preference to see for services:
Fees
I am open to the following Fee Rates per clock hour (check all that apply):*

Sliding Scale or Pro Bono (limited availability)$120-$150 (Newly Provisionally Licensed Clinicians or New Coaches)$150-$185 (Provisionally Licensed Clinicians, Fully Licensed Clinicians, and Coaches)$185-$225 (Fully Licensed Clinicians, Some with Certifications in Specialties, and Experienced Coaches)$200-$350+ (Experienced, Fully Licensed Clinicians with Certified Specializations, and Experienced Coaches)I have no fee concerns.
Please indicate your willingness and/or preference for modality of services: (Check all that apply.)

Prefer In-Person Services (Subject to any Health & Safety Protocols)Prefer Virtual ServicesWilling to attend In-Person Services (Subject to any Health & Safety Protocols)Willing to attend Virtual Services
Do you have insurance (healthcare coverage)?

YesNo
Are you eligible for Medicare Benefits?

YesNo
Aspen Haus Associates does not currently participate as a provider with insurance plans and is a fee-for-service, or private pay, practice. We are required by law to ask if you have insurance either way.

Please see our website for full explanation.
Availability
Please indicate your available for scheduling. Most of our associates offer day time availability during the week. Generally, morning is considered 8 a.m. to noon and afternoon is considered noon to 5 p.m. Associates have limited evenings and weekends available. (Check all that apply.)*

Monday Morning (8 am - noon)Monday Afternoon (Noon - 5 pm)Tuesday Morning (8 am - noon)Tuesday Afternoon (Noon - 5 pm)Wednesday Morning (8 am - noon)Wednesday Afternoon (Noon - 5 pm)Thursday Morning (8 am - noon)Thursday Afternoon (Noon - 5 pm)Friday Morning (8 am - noon)Friday Afternoon (Noon - 5 pm)Other
Agreement
I agree to being contacted by Aspen Haus Associates, LLC to follow up to my inquiry.

I Agree.I Disagree.
I agree to receiving communication via email from Aspen Haus Associates, LLC to prepare for any process or services.

I Agree.I Disagree.
Submission
Please verify that you are human*
Signature

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Should be Empty:

Seeking AHA Services

Contact Information

Permission to Contact

Previous & Other Professional Services

Previous Client?

Other Providers

Referral?

Reason for Seeking Services

Do you have a preference on which provider you see or location?

Fees

Availability

Agreement

Submission