Consultation Request Form

Emily L. Shiraishi, Psy.D., LLC

Please correct the errors described below.

Emergency Assistance

Please do not use this form in an emergency. If you are experiencing an emergency, please dial 911 or go to the nearest Emergency Room.

National Crisis Phone Line: 988
National Crisis Text Line: "Home" to 741-741

First name

Last name

Birth date

Phone number

It is okay to leave a voicemail regarding our meeting at this phone number?

Yes No

Email address

What do you want to work on in therapy?

What are you looking for in a therapist?

I live in Hawaii or Oregon, and therefore am eligible for these services.

I will be in Hawaii during our consultation. I will be in Oregon during our consultation.

I prefer to consult by

Video call*

Please email me a video link to the email address I listed above. *I will email you from an ecrypted email system called Hushmail, which will you require you to sign in to view emails.

Phone call

I understand that Emily L. Shiraishi, Psy.D. is out-of-network with most insurance companies.

I have reviewed the privacy policies at www.emilyshiraishi.com/privacy-policy.

I understand that a consultation does not constitute a therapeutic relationship.

Dates and times I am available for a 15-minute consultation (Please specify which time zone):

How did you hear about my services?

Psychology Today Website Family or friend Healthcare provider Other

Other Notes

Your information will be encrypted.

Emergency Assistance

Please do not use this form in an emergency. If you are experiencing an emergency, please dial 911 or go to the nearest Emergency Room.

National Crisis Phone Line: 988
National Crisis Text Line: "Home" to 741-741

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