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CONSULTATION FORM

Thank you for your interest in The Liberated Self Therapeutic Services.

 

We are currently offering Individual Psychotherapy. Because of limited space and time, all potential clients are requested to fill out our “Consultation Form,” as a way to collect some basic information about you, the potential client, and to determine whether or not we are able to offer you the type of mental health services you are seeking.

 

When filling out the “Consultation Form,” please make sure to complete all parts, as thoroughly as possible. The information that you include in our "Consultation Form" is considered confidential and is protected under HIPAA, a federal law that protects client health information.

 

Notice: If you are CURRENTLY dealing with an emergency or mental health crisis, DO NOT attempt to complete our "Registration Form." Please  dial 911 or call the National Suicide Prevention Lifeline @ 988 or text "NAMI" to 741741 for support. You are also encouraged to reach out to a person you know and trust for additional support.

CLICK IMAGE BELOW FOR CONSULTATION FORM

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