Work With Dr. Cynthia

Thank you for reaching out. In order to determine your current needs, what services you're seeking, and to determine if Dr. Cynthia is the right fit for your needs, there are a few questions for you to complete. This takes only a few minutes. Answer as honestly as you feel comfortable with. All inquires remain confidential.

What is your full name?

What is your email address?

What is your phone number?

How did you find Dr. Cynthia?

What made you reach out now ?

Have you participated in therapy before?

What feels most relevant to what you are currently dealing with (check all that apply):

Please list the days/times you are available to meet. Please note that Dr. Cynthia's schedule to work one-on-one with clients is limited so the more flexibility you have, the better.

If Dr. Cynthia does not have a current opening, would you like to be placed on a waitlist?

Yes

No

How do you plan to pay for services:

I have insurance and want to use it

I prefer to pay privately (out of pocket)

I'm interested in consulting services, not ongoing therapy

I'm interested in having Dr. Cynthia speak at an event or training

I want to join the Burnout Not Broken Recovery Circle when it opens

I'm not sure yet, I'd like to talk through options

If using insurance-please list full name of insurance/group number/primary insurance carrier full name and their date of birth. Please note that Dr. Cynthia accepts a limited number of commercial insurance plans

Therapy works when you're ready to show up consistently and honestly- even on weeks it may be difficult to find the time. Is this something you feel you can commit to?

Yes — I'm ready to commit to weekly therapy

I think so, but I have a busy schedule

Honestly, I'm not sure yet

No — I'm still exploring

Is there anything else that you feel would be important for Dr. Cynthia to know?

Thank you for taking the time to fill this out. Dr. Cynthia reviews each submission personally and will be in touch within 2 to 3 business days.