Request for Consultation Form

Please correct the errors described below.

Tambria Hunt LLC

(318) 228-1978

First and Last Name

Email address

Phone Number

Numbers Only

State of Residence

Best Time to Contact

Reason for Consultation: Please select any areas that apply:

Anxiety or Stress

Depression or Low Mood

Trauma-related concerns

Chronic illness or chronic pain-related stress

Caregiver burnout

Grief or loss

Relationship or family stress

Work or life transitions

Other

Briefly share what you are seeking support with:

Are you interested in virtual counseling?

Yes

Unsure

Are you seeking individual counseling?

Yes

Unsure

Are you hoping to use insurance or private pay?

Insurance

Private Pay

Unsure / would like to discuss

Insurance provider, if applicable:

How did you hear about Tambria Hunt LLC?

Consent and Emergency Notice

I understand that submitting this form does not establish a therapist-client relationship. I give permission for Tambria Hunt LLC to contact me using the information provided. This form is not monitored for emergencies. If you are experiencing a mental health crisis, call 988, call 911, or go to the nearest emergency room.

Preferred Method of Contact

Phone

No Preference

Your information will be encrypted.

Tambria Hunt LLC

(318) 228-1978

Tambria Hunt, PhD, LPC

Licensed Professional Counselor, Tambria Hunt LLC

(318) 228-1978
www.therapywithdrhunt.com

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