Application for Therapy

Full Name *

Phone *

Email *

(This page, and the following, are confidential and private)

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

How did you first hear about me and my practice? (Helps me understand what led you here and what you already know about my work.) *

If someone referred you, who was it? (It’s helpful for me to know the community connections that led you here.) *

Which type of support are you seeking right now?

Individual counseling

Couple counseling

Family counseling

Relationship Intensive

Which of the following best describes your current relationship status?

Please tell us a little bit about yourself, so that we can better understand your situation.

Single

Dating/Long Term Relationship/Engaged

Married

What’s bringing you here at this moment?
(Why does this feel like the right time to begin working on yourself/your relationship?)

Therapy and intensives work best when clients are clear about what they want. What are the changes, outcomes, or breakthroughs you’re hoping for?

(Be as specific as you can. What would “success” look like for you?)

I reserve only a limited number of spaces for new clients. Why do you feel now is the right time for you to step into this work—and what makes you confident you’re ready?

The private pay rate for counseling sessions is $125/50 minute session for individual counseling and $175/50 minute session for couple/family counseling. The insurance plans accepted by Josh are listed below. If yours is not listed, it is possible you may be eligible for out-of-network reimbursement through your insurance plan. Once you complete the questionnaire, you will be take to a screen where you can select to verify out-of-network coverage.

Josh currently accepts the following insurance:

Check the box indicating which insurance coverage or payment option you will be choosing.

Insurance *

Cigna

Aetna

Blue Cross Blue Shield

Private Pay

Waitlist

Josh currently has a waitlist for new clients. If you would like to be added to the waitlist, please check the box below. While on the waitlist, you will receive regular updates until a spot becomes available.

In the meantime, we will also provide you with a list of trusted counselors should you wish to begin therapy sooner.

Please note that it is challenging to estimate when a spot may open up, as the length of treatment varies for each client. You may remove yourself from the waitlist at any time by clicking the link provided in the emails you receive.

Would you like to be added to the waitlist?

Yes, please add me to the waitlist.

Almost There...

Final (and Most Important) Step!

CHECK YOUR EMAIL!

Josh values understanding your situation before moving forward with therapy services. If there is no waitlist, you will receive an email with a link to schedule a free consultation.

For couples/family counseling: All participants must be present for the consultation, which can be done via Zoom or in person.
For individual counseling: Consultations are conducted via phone call.

NEXT STEPS

STEP 1

Check your email for either a waitlist confirmation or an invitation to schedule your consultation.

STEP 2

Follow the link in the email to schedule your consultation at a time that works best for you. You’ll receive appointment reminders via text or email.