Page 1 of 2

Are We a Good Fit for Office Sessions?

Welcome friend! Let’s Find Out!!

Thanks for your interest. This short form helps us both make sure we’re a good match.

My comfy boutique office is in the Americana Building, on the lower level, Suite 100.

Your full name:

Your state of residence:

Date of Birth:

Your email address (no spam):

Your phone (no spam):

How did you hear about Katharine?

A
B
C
D
E
F
G

You understand Katharine works only with individual adults:

A
B

Katharine's current openings for office visits are in the window: Tuesday through Friday 1pm-4pm What time in that window might work for you? (For video visits, go here: https://tally.so/r/mVXbVy)

You are seeking treatment for Eating Disorders, Erectile Dysfunction and/or ADHD?

A
B
C
D

You understand Katharine's rate for in-office sessions is $189 self-pay only, paid in advance to secure your appointment:

A
B
C
D

What would you like to discuss in meetings? (Even a vague idea is okay:)

If you've worked with a counselor before, what was good about the experience? Not so good?

Briefly, how do you usually respond when things don't go the way you planned?

Briefly share on how things might look a month from now if you felt more in control of your situation... What would be different about your life?