Name * First Name Last Name Preferred Name: Please tell us your preferred name you wish us to address you by. How old are you? * Gender Identity Please share with us your gender identity so that we may address you with the correct pronouns. Select Male Female Transgender Binary Other Phone * Your phone number to contact you by phone or text. (###) ### #### Email * Please provide an email address we can contact you at. Where are you located? * We provide online counseling in the following states: Texas, Florida, and Vermont. Tell us more about the type of therapist you are looking for * Your ideal therapist would be some who? How would they support you? I want a therapist who is (please check all that apply). * This information will help us identify your needs that you may not have mentioned above. BIPOC Identified or Allied. Body Positivity Aligned. LGBTQIA+ Identified or Allied. Polyamory Friendly Sex Kink Positivity. CIS Female CIS Male Other (please identify other above). None What type of counseling are you looking for? * This information will help us align you with the right therapist. Select all that apply. Individual Counseling CBT Therapy DBT Therapy EMDR Therapy Trauma Therapy Couple Counseling Discernment Counseling Family Counseling When would you like to start counseling? Select one that apply to you Immediately (with in next few days) As soon as possible (with in next week) Other Would you like weekly or bi-weekly appointments? select one: Weekly Appointments Bi-weekly Appointments Appointment has needed (more than once a week). How would you like to pay for your sessions? * This will help us match you with a therapist who takes your insurance or matches your budget. Select Private Pay Insurance If you selected insurance for a payment option. What is the name of your insurance provider? If you are private pay, what is the amount you are looking to pay per session? * Name of your insurance provider or budget for private pay. Disclaimer: I agree to the following terms and conditions: I understand I am completing this form to be match with a therapist from Mending Hearts Counseling. By checking this box I agree to give Mending Hearts Counseling staff or employees permission to use the information provided to match me with a therapist. I understand that my information with be shared with the therapist matched. Should Mending Hearts Counseling not able to match me with their therapist Mending Hearts Counseling will provide me with referral in the community. Thank you! for completing this form. We will contact you by email with your therapist matches.
