Work with Me

Work With Me Questionnaire

Complete and submit this form if you are interested in becoming a client of Josh Kellar
Client's First Name*
Client's Last Name*
Email Address*
Phone Number*
Partner's First Name (If Applicable)
Partner's Last Name (If Applicable)
Partner's Email Address (If Applicable)
Partner's Phone Number (If Applicable)
Brief description of reason for seeking therapy.*
What makes you ready for counseling right now?*
What do you want most for your relationship right now?*
How did you hear about Josh Kellar Counseling, PLLC*

Google SearchSocial Media (Facebook/Instagram/Other)Referred by Another ProfessionalPersonal ReferralOther
Who were you referred by?*
How did you hear about Josh Kellar Counseling, PLLC
How did you decide to work with Josh Kellar?*
The type of therapy we are interested in is:

Regular (weekly or bi-weekly) Couples CounselingDiscernment Counseling (One partner is unsure about staying in the relationship)Marathon Intensive (Half-Day, Full-Day or Multiple-Day Session)Individual CounselingOther
Health Insurance

Josh is currently not accepting insurance. It is possible though, that a portion of the cost of counseling with Josh Kellar might be reimbursed through the submission of a superbill. During the consultation, you can ask about how to submit documentation for possible reimbursement.

The cost of sessions will be discussed during the free intake consultation.
Who is your health insurance with? Please list the company.*
(PPO, HMO, None/Private Pay)
Insurance Company Phone Number
Find this on the backside of your insurance card.
Insurance Member ID
Insured Client's Date of Birth

MonthDayYear
Date
Thank you for your interest in seeing Josh Kellar for counseling. Once you click submit your information will be reviewed and Josh or his assistant will be in touch.

Submission of form does not constitute an agreement to establish care.

All your information will be kept confidential.
Would you like to receive periodic emails from Josh about how to grow in your relationships!*

Yes, I'd like to receive emails.No, thank you.
Should be Empty:

Work With Me Questionnaire