Secure Contact Form

Thank you for contacting Project Freda Inc. We will reply to your inquiry as soon as possible, and within three (3) business days. If you are experiencing an emergency and are at risk of harming yourself and/or others, please do not use this form. Instead, please call 911 or visit your nearest emergency room.

Please complete and submit this form. Your submission will be encrypted and secure. We will contact you as soon as possible, within three (3) business days of your submission. Fields with a red asterisk (*) are required.

Full Name (first and last)

Potential client's Date of Birth

What are your/the potential client's pronouns?

Has the potential client been released from incarceration within the last 12 months?

Yes

Is the potential client an immigrant? (Immigration status documented/undocumented not relevant)

Yes

Your email address

***Please note: It is Project Freda's policy to send emails via Hushmail and in an encrypted state, in order to protect your information. Upon receipt of our email, you will be required to establish and use a passphrase in order to open the email. We will send emails with encryption unless otherwise requested by you below. Please keep in mind that unencrypted electronic communication is allowed at your request, but is at risk for interception and could result in misuse of personal information by unintended third parties.

No, please do NOT use encrypted email communication with me at this time.

By clicking the box above you acknowledge and accept the risks involved with open, unencrytped email communication and that your personal information could be intercepted by unauthorized third parties.

Phone Number

What type of phone number did you provide?

Cell phone

Work phone

Home phone

Are we permitted to leave a voicemail message regarding scheduling?

Yes

Please provide a "code word" to be used in case a Project Freda Inc. staff member needs to verify your identity over the phone, or, if you would like to verify the individual calling is a Project Freda Inc. staff member. This code word should be easy for you to remember and should not be shared with anybody. You may change your code word with us at any time.

Does the potential client have health insurance?

Yes

Please list the name of the potential client's insurance company.

Is this a Medicaid plan?

Yes

What language does the potential client prefer to use?

On what days might you/the potential client be available for appointments? (Please check all that apply). NOTE: Weekend availability varies and may be discussed with our office prior to scheduling the first visit.

Monday

Tuesday

Wednesday

Thursday

Friday

What time of day is preferred? (Please check all that apply) Please note this does not guarantee an appointment during these hours. This is to assist us with determining the best possible therapist for you/ the potential client.

Morning (8am-12pm)

Afternoon (12pm-5pm)

Evening (5pm-7pm)

Would you/the potential client prefer to be seen in person or online? Please note that all first (intake) appointments are in-person. Subsequent online services are not guaranteed to be available to all individuals

In-person

Online

No preference

Desired characteristics in a therapist

Please describe to us what characteristics you would like in a therapist. For example, female/male, age, experience in certain areas, etc.

Please briefly describe the reason(s) for your interest in receiving therapy services.

Your information will be encrypted.