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Pro Bono Therapy w/ Hakeem!

Thank you for your interest in my clinical practice ๐Ÿ˜ƒ Please fill out this form to help me get to know you better and determine if I'm a good fit to meet your therapeutic needs. All information is kept strictly confidential and will not be shared with any other parties ๐Ÿ”

Email Address

Preferred Name

Age

Gender Identity

Sexual Orientation

Race / Ethnicity

Anything else you'd like to share about yourself?

What type of therapy are you interested in?

What type of therapy are you interested in?

What's your reason for seeking therapy?

What topics or concerns might you want to explore in therapy?

This list is non-exhaustive, but please select any of the following topics that may emerge during the course of therapy.
What topics or concerns might you want to explore in therapy?
What topics or concerns might you want to explore in therapy?

Are you able to commit to attending in-person sessions on a weekly basis?

Sessions will be held on Thursdays at 4380 S Syracuse Street, Suite #308, Denver, CO 80237. If you miss or cancel a session without adequate notice (48+ hours), services will be terminated. Please do not select "Yes" if you are unable to commit to the therapeutic process in its entirety.
Are you able to commit to attending in-person sessions on a weekly basis?

Do you consent to certain sessions being recorded for training purposes?

As an intern, I'm required to record some sessions to develop my clinical skills. Recordings are strictly confidential and deleted immediately after use in supervision. You will always retain the right to decline the recording of a session when sensitive subjects are being discussed.
Do you consent to certain sessions being recorded for training purposes?

Can you commit to a minimum of ten (10) therapy sessions?

The length of therapy will depend on a variety of factors, but a minimum of 10 sessions is generally requested to ensure skills development and adequate therapeutic progress.
Can you commit to a minimum of ten (10) therapy sessions?