Radical Essence Therapy PLLC Initial Intake Form (RRP Coaching)

Intake for Pre-Interview.

Thank you for filling out this form. If I believe that an RRP group is best for your current needs, & I have the space available, then I will contact you within 1-2 weeks for an interview. Please re-apply in the future if space is full, or if you are currently needing more specific individual care (stabilization). I wish you the best!

First Name

Last Name

Email address

Primary Location/Residence (City, State, & Country)

Your Time Zone

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. Sliding scale spots are available but limited. [$25 x 4 = $100 monthly. $100 x 6 months = $600.] [$50 x 4 = $200 monthly. $200 x 6 months = $1200].

Yes, I am aware.

I would like to apply for a sliding scale ($25 or $50). I understand that these may be full.

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