Confidential Client Intake Form

The information you provide here will be kept confidential and will be helpful in knowing how best to support you. Please answer each item to the best of your ability.


My standard rates are $130/hour.

If these fees are prohibitive, please send me a message explaining your situation. I am open to renegotiation at any time so that our exchange feels sustainable for us both. I ask that clients commit to 4 sessions before deciding to continue.

If any difficult feelings have come to the surface from filling out this form, please take a deep breath and remember that you are safe. Consider going for a walk in nature or calling a trusted friend to share what has arisen. Offer yourself some appreciation for the courage to complete this form.