Adult Consultation Form

Welcome!

Thank you so much for reaching out to Sunrise Child Counseling! I know taking the first step toward therapy can feel overwhelming, and I appreciate you taking the time to complete this consultation.

Rather than offering phone consultations, I begin with a written consultation process. This gives you the opportunity to thoughtfully share what's been going on while allowing me to carefully review your concerns and determine whether I may be the right fit. It should only take about 3–5 minutes to complete.

I'll personally review every consultation and respond within 1–2 business days. If I believe we'd work well together, I'll reach out with the next steps for scheduling. If I don't believe I'm the best fit, I'll let you know and provide referrals to therapists or resources that may be a better match.

You'll also find a section at the end of this consultation where you can ask me any questions about my approach, the therapy process, scheduling, or anything else that's important to you. Once I've reviewed your responses, I'll answer your questions via email. Finding the right therapist is an important decision, and I want you to feel confident that I'm the right fit before moving forward.

Please share as much or as little detail as you feel comfortable. The more context you provide, the better I'll be able to understand your concerns and determine how I can best help.

Basic Information

First and Last Name:

Email Address:

Phone Number:

Preferred contact method? (Check all that apply.)

Text

Call

Age?

Preferred pronouns?:

She/her

He/him

They/them

Other

Prefer not to say

If other, what are your preferred pronouns?

City, State

Practice Information

How do you plan to pay for therapy? I only accept BCBS, Aetna, or self-pay. Please verify your behavioral health benefits with your insurance company prior to scheduling. I can also provide a superbill for my out-of-network clients to help with reimbursement.

BCBS Aetna Self-pay Not sure

All sessions are conducted virtually through a secure telehealth platform.

I understand.

My practice hours are Tuesday through Thursday. The latest available appointment begins at 5:30 PM.

I understand.

Therapy typically begins with weekly sessions to build consistency and therapeutic rapport.

I understand.

Attendance and Cancellation Policy

Please review my attendance policy before submitting your consultation.

Appointments canceled with less than 24 hours' notice are charged a $75 late cancellation fee. Missed appointments without notice are charged the full session fee. Clients who repeatedly miss appointments or go three consecutive weeks without attending a scheduled session may be discharged unless other arrangements have been discussed in advance.

I understand.

Presenting Concerns

What brings you to therapy?

Briefly describe what prompted you to reach out and what you'd like help with.

If other, what concerns bring you to therapy?

What are you hoping will be different if therapy is successful?

Have you participated in therapy before?

Yes No Not sure

If yes, what was helpful? Is there anything that wasn't helpful?

Are any of the following true for you? (Check all that apply.)

I am currently experiencing thoughts of harming myself.

I have attempted suicide or been psychiatrically hospitalized within the past year.

I am currently involved in legal or court proceedings that may affect my therapy.

None of the above.

If you checked one of the above answers, can you please explain further?

If you are currently experiencing a mental health crisis, please do not wait for a response to this consultation form. If you are in immediate danger or are unable to keep yourself safe, call 911 or go to your nearest emergency department. You can also call or text 988 to reach the Suicide & Crisis Lifeline for free, confidential support 24 hours a day, 7 days a week. If available in your area, your local mobile crisis team may also be able to provide immediate support in the community.

What are some of your strengths, hobbies, or interests?

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

Questions for Me

Do you have any questions for me about my approach, the therapy process, scheduling, or whether I may be a good fit?

Please don't hesitate to ask! After I've reviewed your consultation, I'll respond to your questions via email when I follow up about whether I believe we'd be a good fit and the recommended next steps.

Acknowledgment

I understand that completing this consultation form does not guarantee services and is used to determine whether Sunrise Child Counseling is an appropriate fit for my needs.

The End!

Thank you for taking the time to complete this consultation. I know sharing your concerns can feel vulnerable, and I appreciate you trusting me with this information.

Once you're ready, click Submit below, and I'll personally review your responses and follow up within 1–2 business days. If you included any questions for me about my approach, the therapy process, insurance, or anything else, I'll be sure to address those in my response as well.

If it looks like we're a good fit, I'll send you information about scheduling your intake appointment and completing your intake paperwork through the client portal.

If it seems another provider would be better suited to your needs, I'll do my best to provide referral options whenever possible.

I really appreciate you reaching out and look forward to connecting with you soon!

Your information will be encrypted.

Adult Consultation Form

Welcome!

Basic Information

Practice Information

Attendance and Cancellation Policy

Presenting Concerns

Questions for Me

Acknowledgment

The End!

Katey Smith

Sunrise Child Counseling