Radical Essence Therapy PLLC Initial Intake Form (RRP)

Intake for Pre-Interview.

Thank you for filling out this form. If I believe that an RRP group is best for your current needs, and I have the space available, then I will contact you within 1-2 weeks for an interview. No contact does not necessarily equate to a poor fit for groups. Please re-apply in the future if space is full. If you are needing more individualized, intensive care, then please feel free to visit the resources page on my website to learn more about intensive outpatient programs (IOPs). I wish you the best.

First Name

Last Name

Email address

Primary Location/Residence in North Carolina (City, Zip)

I have experienced suicidality within the past year.

Yes

I've needed partial or inpatient hospitalization in the last year.

Yes

What has been helpful to you as a person (I.e. therapy, books/podcasts, 12-step groups, programs/clubs, medication, &/or other internal/external resources)?

What might you’d like to heal and/or change?

What led you to this moment in seeking change (a recent break up, hearing a relatable story, a dynamic or calling that keeps prompting you, etc.)?

Is there anything else you'd like to add or want me to know?

I am aware that RRP group sessions cost $75 per 90-minutes. Good Faith Estimate: $75 x 4 = $300 monthly. $300 x 6 months = $1800. (Short-Term Groups) $75 x 4 = $300 monthly. $300 x 36 months = $10,800. (Long-Term Groups)

Yes, I am aware.

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