Contact Page & Sidebar Widget

Name

Date of Birth

(MM/DD/YY)

Do you confirm that you are at least 18 years old? Embodied Empowerment does NOT provide therapy to individuals under 18 years old

Yes No

We will respond to your appointment request at the email you provide here. Please make sure it is private and that you are comfortable communicating with us on whatever email you provide.

Phone

Address

(Street, City, State, Zip Code)

Are you currently located in the state of Arizona? Embodied Empowerment cannot provide counseling services to individuals who are not physically located in the state of Arizona at the time of their session.

Yes No

Do you understand and acknowledge that your sessions will be held via telehealth? Online therapy requires a private space, internet connection, and device with a video ability

Yes No

Will you be using insurance benefits to cover your sessions? Jessica Byrd, LCSW is contracted with Lyra Health. Benefits through any other insurance provider are not covered.

I will be a cash pay client I will be using Lyra Health to cover my session costs I would like to find a provider covered by my in-network insurance benefits

If you referred by a family member, friend, or provider please list their name or practice

If you found us in an online search, what did you search to find us?

Your answer helps us market our practice in a way that is accessible to everyone!

Are you currently working with any other providers (i.e. a dietitian, physician, psychiatrist, or counselor)?

Yes No

If yes, are you willing to provide us with permission to speak with them about your clinical care?

Yes No

Do you have a provider you would prefer to work with?

I would prefer to work with Danielle I would prefer to work with Jessica I don't have a preference

Please provide us with a brief description of the concerns you would like to address in counseling:

Is there anything else you want us to know?

Please note that Embodied Empowerment does NOT provide crisis services. If you are experiencing a clinical emergency please DO NOT complete this form as no clinicians are monitoring this website outside of office hours. If you are in crisis please call 911 or visit your nearest emergency room.

Your information will be encrypted.