TELEHEALTH ONLY

〰️

TELEHEALTH ONLY 〰️

I am ready to begin my journey.

Name

First Name

Last Name

Date of Birth

YYYY

Phone Number

(###)

###

####

Have you been to therapy before?

Do you identify as a woman of color?

What are your therapy goals?

How did you find Essential Grace Counseling?

Payment Method

If your insurance is not listed, we are an out-of-network provider and you will be required to self-pay.

Insurance Subscriber ID

If you are paying with insurance, please provide your insurance information.

I would like to schedule with...

Please choose the clinician you would like to work with.

By submitting this online referral request, you consent to Essential Grace Counseling, PLLC reaching out by email or telephone/voicemail.

I consent

Your journey begins with scheduling a free 15-minute telephone consultation. It’s purpose is to get an idea of what your psychotherapist is like and whether they are a good fit for you. It is also the time to go over logistics such as session fees and scheduling. You are also encouraged to ask your psychotherapist questions.

TELEHEALTH ONLY

〰️

TELEHEALTH ONLY 〰️

I am ready to begin my journey.

Location

Hours

Contact