Consultation Request

Completing this form electronically and clicking the submit button will result in it being sent securely to Christy.

First and Last Name

Your Partner's First and Last Name if you are seeking Couples Therapy

What are your preferred pronouns? What are your partner's preferred pronouns if you are seeking couples therapy?

Email Address

Phone Number

Your Partner's Email Address if you are seeking couples therapy

Your Partner's Phone Number if you are seeking couples therapy

Please provide me with a few sentences summarizing the issues you are seeking help with

I am immunocompromised, so I'm meeting in person with people who are vaccinated (usually 2 shots) and have received a booster (3rd shot) for COVID-19, and I'm meeting by secure, HIPAA compliant video conferencing with everyone else. Please select the first box if you're vaccinated and boosted, or select the second box if you have not been vaccinated and boosted for COVID-19 and are willing to meet by video conferencing for your therapy.

We are fully vaccinated and have received a booster shot for COVID-19 (each person has received 3 or more shots).

we are not vaccinated and boosted for COVID-19 and are willing to meet by video conferencing for our therapy.

Please enter my email addresses and phone number below into your phone and email contacts list so that my emails to you will not go to your spam folder and so my call to you for the consultation will go through as an identified caller. Please check the boxes below once you have done so.

christy.kobe.lcsw@gmail.com

christy.kobe.lcsw@therapyemail.com

385-743-8731

Describe any previous experiences you've had with counseling or therapy. What worked well for you, and what did not?

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