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Are We a Good Fit for 1:1's?

Welcome friend! Let’s Find Out!!

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

No phone calls, no pressure; just a quick form then I'll be in touch!

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?

How did you hear about Katharine?
A
B
C
D
E
F
G

Are you completing this form for yourself, or on behalf of someone else?

Are you completing this form for yourself, or on behalf of someone else?
A
B
Please note: To protect privacy and maintain HIPAA compliance, I can only review intake forms completed directly by the adult seeking counseling. However, any adult needing accessibility assistance may receive help completing the form while remaining actively involved in the process.

You understand that Katharine can provide counseling to residents of California, Idaho and Texas, but if you reside outside of those states, you are signing up for coaching:

You understand that Katharine can provide counseling to residents of California, Idaho and Texas, but if you reside outside of those states, you are signing up for coaching:
A
B

You understand Katharine works only with individual adults:

You understand Katharine works only with individual adults:
A
B

Most of Katharine's clients have professional jobs and find it doable to carve out an hour during the week for the process. If that's you, we're probably a good fit. Katharine's current openings are Tuesday-Friday, 8am MST to 2pm MST. In that time frame, what works best for you?

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

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

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

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

If you'd like to use insurance for video sessions, please indicate your insurance carrier, and if you feel comfortable, your member ID so Katharine can check your copay:

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

How would things look a month from now if you felt more in control of your situation? What would be different...?