Request for Therapy Form

Please correct the errors described below.

Hello there! Thank you for taking the time to tell me more about yourself and your therapy needs. I'm so glad that you reached out.

Please note that this form is confidential and private and will delivered to me through an encrypted email platform. Filling out this form is the first step to see if your therapeutic needs meet with my experience and expertise.

Please note that the completion of this form neither means I am your therapist nor means that I have availability in my schedule to receive new clients. The goal of this form is to help us determine if my expertise and your therapy needs match. The client/therapist relationship is important, and I want to make sure I'm the right fit for you.

With your best interests at heart, I do not accept health insurance, and am considered a "private pay therapist." If your insurance plan allows, you may be able to use my services as an out of network provider.

If you wish to use your health insurance, and you are looking for referrals, I would recommend using the find-a-therapist search engine located on Psychology Today.

Whew ... now that we got all the legal stuff out of the way ... let's get to the good stuff! :)

Your Contact Information

Health Insurance Usage

Referral Resource

Therapist Preferences

Past Therapy Experience

Past Psychiatry Experience

Suicide and Thoughts of Death and Dying

Support Systems and Close Relationships

Therapy Needs

Getting In Touch

Thank you for taking the time to fill out this secure form. Once you click on the "submit" button, it will be delivered to my encrypted email inbox. Upon receiving this information, I will contact you so we can discuss this information further.

Thanks, and I look forward to talking with you soon. --Tim

Your information will be encrypted.