Consultation for Individual Counseling Services

Emergency Assistance

Emergency Medical Services 911
National Suicide Prevention Lifeline 988

Please complete and submit the following form for consideration for individual counseling. Your responses will be reviewed and you will be contacted in 48 hours (excluding weekends and holidays) via phone, if applicable to discuss your counseling needs. During this brief phone conversation, you will have an opportunity to ask questions about working with me or the counseling process. Submitting this form is not an agreement to receive counseling services; however, it is the first step in the process. If applicable, the next steps include a brief phone discussion about your counseling needs and scheduling your first session. Also, be sure to review https://www.freedomfocusedcounseling.com for more information on counseling services provided, insurances accepted, self-pay rates and hours of operation, etc. Please read before completing this form: *You are NOT a candidate for tele-mental health counseling at Freedom-Focused Counseling, LLC, if you are currently endorsing suicidal or homicidal thoughts with an active plan or intent, attempted suicide in the past 2 years, admitted into a psychiatric hospital for mental health challenges in the last 5 years, hearing or seeing things that are not there, substance abuse behaviors, or eating disorders. If it is unclear if you are a candidate for tele-mental health support, feel free to contact me at info@freedomfocusedcounseling.com* **If you are currently in a mental emergency or crisis and experiencing thoughts of suicide, homicide, self-harm, or have a plan for suicide, homicide or self-harm, please call 988 now or go to the nearest emergency room for assistance.**

You must be at least 18 years old for individual counseling services. If you are not at least 18 years old, please exit this form now.

Yes No

What is your name? * Please provide your first and last name.

What symptoms or challenges are you experiencing at this time? Please check all that apply.

Anxiety

Anger

Stress

Grief/Loss

Depression

Relationship Conflict

Transition/Adjustment Issues (new baby, school, city, job, marriage, etc.)

Trauma (PTSD, domestic violence, childhood abuse/neglect)

What has prompted you to reach out for counseling services?

Have you previously received counseling? If so, when and if diagnosed, what was your diagnosis?

How did you learn of my practice?

Google/Internet Search Therapy for Black Girls Psychology Today Friend/Family Member Social Media Other

Are you available to meet virtually for counseling sessions? * All counseling sessions are online and conducted via a secure and HIPAA compliant app.

Yes No

If you plan to use insurance, do you agree to contact your insurance provider prior to your first appointment to learn what your financial responsibility will be for services?

Yes, I agree Yes, I agree; but I will need some guidance on this process

What is your availability to meet for counseling sessions? Please check all that apply.

Daytime Weekday (9am-3pm EST) Evening Weekday (4pm-6pm EST)

What is the city and state of your current residence?

What is your phone number? * Please provide your phone number to receive a follow-up call in scheduling your first session, if applicable.

What is your email address?

What is your availability for a brief phone call to discuss your counseling needs and schedule your first session, if applicable? Please be specific in providing days and times during the workweek when you are available.

Would you like to share additional information not asked or addressed on this form? Is there anything else you would like me to know at this time?

Your information will be encrypted.

Consultation for Individual Counseling Services

Emergency Assistance

Emergency Assistance

Mauranda N. Jones, LCSW, BC-TMH, BCD

Freedom-Focused Counseling, LLC