Name *

First Name

Last Name

Phone *

(###)

###

####

Referral Source *

Psychology Today

Online Search

Other

Are you looking for individual or couples sessions? *

Individual

Couples

I only see adults in my practice. Please select your age range. *

18-24

25-34

35-44

45-54

55+

Are you interested in in-person or telehealth sessions? You must be a resident of Washington State to receive telehealth therapy. *

In person

Telehealth

I am not in-network with any insurance providers and am a private pay practice. My fee for individuals is $175/session and my fee for couples is $250/session. Please confirm you have read and understand this. *

I have read the above and will be paying out of pocket.

Disclaimer *

I understand that submission of this form and any resulting consultation communication with Flowing Therapy PLLC does not in itself initiate a therapeutic relationship between myself and Flowing Therapy PLLC. I understand this form is not intended to address time-sensitive matters or to receive immediate emergency support.