NEW CLIENT QUESTIONNAIRE

Thank you for your interest

in working together!

I would be honored to support you on your journey toward wholehearted wellness and holistic healing. Before we begin, let’s make sure that we are a good fit, where my approach and specializations will be the best match for your therapeutic goals and interests. Fill out the form below and I will be in touch within 48 business hours to follow up. Looking forward to connecting with you soon!

First Name

Last Name

Please share a brief description of why you are seeking therapy and your most pressing concerns that you would like to explore in counseling?

What are your top 3-5 goals for counseling?

What do you believe has gotten in the way of you accomplishing / addressing those goals previously?

What specifically about my offerings and approach interested you?

Were you referred to Mindful Therapy with Keri by someone? If so, whom?

In counseling, we often speak of the importance of clients being both ready and willing to embark on the therapeutic journey. Do you feel that you are both willing and ready for counseling? If so, please briefly share why. If not, please briefly share why.

What days and times typically work best for your schedule? Please provide a few options.

Do you have a preference for in-person or Telehealth counseling? If in-person sessions are not available, are you open to Telehealth counseling?

Are you aware of my fees and out-of-network insurance policy? (visit https://www.mindfultherapywithkeri.com/fees for more information)

If there is anything else that you think would be helpful for me to know about you or if you have any particular concerns, please share here.

Thank you for taking the time to wholeheartedly answer these questions! I will be in touch within the next 48 business hours to follow up.