Please read the following information carefully before completing this questionnaire.

Completing this questionnaire does not establish a therapist-client relationship, does not constitute informed consent for treatment, does not schedule an appointment, and does not guarantee that therapy services will be offered.

Submission of this questionnaire does not obligate either you or me to enter into a professional relationship. I reserve the right, in my professional clinical judgment, to determine whether my practice is an appropriate fit for your needs and whether I am able to provide services. Completing this questionnaire does not obligate me to contact you, respond to your inquiry, schedule a consultation, or offer therapy services. I may decline to offer services or may be unable to respond to every inquiry. Likewise, completing this questionnaire does not obligate you to pursue therapy with me. You are free to discontinue the inquiry process at any time.

This questionnaire is entirely voluntary and is intended only as an initial inquiry to help determine whether my practice may be an appropriate fit for your therapeutic needs.

Before completing this questionnaire, please be aware that my practice has the following requirements:

• I provide psychotherapy only to clients who are physically located in the State of Ohio at the time services are provided.

• I provide telehealth services only. I do not offer in-person appointments.

• My practice is private pay only. I do not accept insurance or bill insurance companies.

• My current fee is $175 per 50-minute therapy session. By submitting this questionnaire, you acknowledge that you understand this fee and are willing and able to pay for services if I decide to extend an offer of providing therapy services to you, and if you should decide you wish to hire me as your therapist.

Please also note that I do not provide crisis services under any circumstances. My practice is not equipped to provide emergency, urgent, or after-hours mental health care. If you are experiencing thoughts of harming yourself or someone else, are in emotional crisis, or require immediate psychiatric or medical attention, please do not submit this questionnaire or wait for a response from me. Instead, call 911, go to your nearest emergency department, or call or text 988 to reach the Suicide & Crisis Lifeline.

All questions on this questionnaire are optional. You are never required to disclose information you do not wish to share. However, the more information you choose to provide, the better I may be able to understand your concerns and determine whether my practice is likely to be a good fit.

If therapy services are ultimately offered and accepted, information you voluntarily provide in this questionnaire may be incorporated into your clinical record and used to assist with assessment, treatment planning, and the provision of services.

By choosing to submit this questionnaire, you acknowledge that you have read and understood the information above, that this questionnaire is an inquiry only, that no therapist-client relationship has been established, that no response or contact is guaranteed, and that no guarantee of services is made by submitting this information.

Anyhow. Now that all that’s outta the way.

I hope you have as much fun taking this questionnaire as I had writing it. I’m not a robot just because I’m a therapist, so this questionnaire honestly functions as a two way street for us getting to know each other. I get to see if you’re a good fit for becoming my client, and you get a sense of my values and worldview and if you wanna hire me. Of all the questions that could possibly be asked, it’s not an exhaustive list, but it’s a fun list.

If any of this is like, “huh? what? I just wanna feel better and I’m not sure what all this means,” don’t worry, you’re probably not who I’m trying to filter for.