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?

My private pay rate is $125 per 50-minute individual session. Couple and family sessions range from $125–$175 per 50-minute session depending on the service and payment method. Intensives are quoted separately. I do not bill insurance directly, but many clients choose to seek out-of-network reimbursement. After you submit this form, you’ll have the option to check your potential reimbursement through Mentaya. Please confirm below that you understand and agree to the self-pay structure.

Yes, I understand and am prepared to self-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!

After submitting your questionnaire, you’ll be automatically redirected to schedule your consultation and complete the refundable deposit. This step helps ensure that your spot is reserved and that we begin our work with intention and clarity.

For couples/families: Everyone involved needs to be present for the consultation—either on Zoom or in person.

For individuals: Consultations take place by phone.

NEXT STEPS

STEP 1

Pay the refundable deposit and schedule a consultation.

STEP 2

Show up for the consultation ready to explore how to grow personally and relationally!