Page 1 of 2

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.

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

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

Katharine's current openings are for video sessions at the following times... Tues 8am MST Wed: 11am, 12pm MST
Thurs: 12pm MST Which, if any, of these times might work 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?
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:

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

If you'd like to use insurance for video sessions, please indicate your insurance carrier, and if you feel comfortable, your policy numbers so I can check your benefits and copay:

What would you like to discuss in meetings with me? (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...?