Online Consultation Form

New Client Online Consultation

If you are experiencing a life-threatening emergency or need immediate assistance, please call 911 or go to your nearest emergency room. Please do not use this form for emergencies or urgent matters. I do not provide crisis sessions to new clients.

National Crisis Line: 1-800-273-8255

Name

Phone Number

Email address

Insurance

Only BCBS and Lyra EAP accepted. Superbills for out of network reimbursement are available.

Primary Reason for Appointment

Mental Health Treatment History

Please note the reason for treatment. If this is your first time seeking therapy, please mention it above.

Is there a type of therapy you are interested in?

No preference Yes

If yes, please explain below.

Explanation

Are there any qualities you want in a therapist?

No preference Yes

If yes, please explain below.

Explanation

Preferred Day(s) and Time(s) for Appointments

Office Hours: 11AM-6PM Monday-Thursday

Please note that there are conditions or situations that are outside of my ability or training to treat. If this is the case, you will be provided with referrals to other providers or treatment programs.

Online forms, emails, and phone calls are responded to Monday-Thursday 11AM-6PM. If you reach out to me outside of these hours, I will contact you within 2 business days.

Your information will be encrypted.

Online Consultation Form

New Client Online Consultation

New Client Online Consultation

Kasey Meyer, M.A., LPC