Client Interest Form | Therapy is my J.A.M.

Thank you for reaching out to Therapy is my J.A.M., LLC.

Please take a few minutes to tell me a bit about yourself so that I can learn about your needs, and how best to serve you.

What is today's date?

Month

Day

Year

First name

Last name

Birthday

Month

Day

Year

What is the best email to send documents and communication to?

What is the best phone number to reach you?

Are you a resident of Maryland or Washington D.C.? (I am only licensed to see clients in these two areas)

Which therapy services are you interested in? (ONLY BCBS & Cigna Insurance is accepted)

Individual (BCBS Insurance)

Individual (Cigna Insurance)

Individual (Private Pay - $150)

Couples (Private Pay - $180)

If you are interested in Couples Therapy, what is your partner's first and last name?

If you are interested in Couples Therapy, what is your partner's email address?

Are you currently struggling with any of the issues below?

Drug Use

Alcohol Use

Legal Action

None of the Above

Do you currently have any thoughts or desire to harm yourself or someone else?

Yes

No

Do you have any history of suicide attempts or suicidal ideation in the past?

Yes

No

What has caused you to seek therapy at this time?

What are you hoping to gain from therapy sessions?

What days would be best for regular appointments?

What times would be best for regular appointments?

Would you like a 15 minute intro call?

Yes, I'd like to speak to you before I book a session

No, I'm ready to book my first session

How did you hear about my services?

Would you like to stay in touch by subscribing to my newsletter where I share upcoming events and the Monthly Jam (journal prompts, affirmations & mindfulness challenges)?

Yes, I would like to subscribe to your newsletter.

Interested in

Being a Client