New Client Booking Form Sliding Scale Application Name * First Name Last Name Email * Why are you seeking therapy at the moment? What are your goals? What about my approach is appealing for your support and growth? * Do you have a history or current thoughts of self harm, suicide or harm to others? * Are you on any medication, if so for what? * Have you seen a therapist before? Explain. * How were you referred to me? * Checkbox * Private Pay (starting at $215/session for individuals and $250 for couples) Sliding Scale (must fill out application- starting at $180 ) Out-of-Network Superbill (call your insurance and ask if you have out of network benefits) Thank you! Kali will be in touch soon.
