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Clinical Therapist- IT
IC CT position
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Contact Form- For Clients under 18 years old
**If you do not get a response in 3-5 business days, please check your spam/junk folder before following up. **
*
Indicates required field
Potential Client's Name
*
First
Last
Legal Name (if different)
*
First
Last
Email
*
Can we contact you and use your name via phone?
*
Select
Yes, you can call but do not use my name for safety reasons
No, email communication only
Yes, you can call & use my name
This option is to help protect our more vulnerable potential clients.
Can we text you?
*
Yes
No
Text reminders ONLY
Please note, we cannot do therapy via text. Texting is for basic communication ONLY
Phone Number
*
Client's Pronouns
*
If you feel comfortable, please write which pronouns we should use when addressing you.
Is the potential client willing to participate?
*
Select
Yes, I, the client, am willing to participate
Yes, I am inquiring on behalf of the client, and they are willing to participate
Kind of, they are open to hearing more before making a decision
No, I am inquiring on behalf of the potential client but they either do not know or are not willing
No, but they are court mandated
This section will be confirmed before therapy is started. Clients must be willing to participate in order for therapy to work to its fullest. Hesitation is normal but we want to make sure we are respecting autonomy as well.
How did you hear about us?
*
Select
Social Media Ad
Google Search
Psychology Today
Therapy Den
Inclusive Therapists.com
Friend/ Family referral
Health Care Professional Referral
TAC referral
Other (please explain below)
Why? This helps us see where our clients are finding us so we can determine where to place our resources to help become more visible to potential clients who may be looking for services like ours.
If Other, please explain:
*
If health care professional referral, please list doctor/organization/clinic
*
What is your relationship to the client?
*
Select
I am the potential client
Custodial Parent
Non-Custodial Parent
Guardian
Foster parent
Case worker
Other (please explain below)
If selected "other" to relationship, define here
*
Parent/Legal Guardian's name:
*
First
Last
Parents and guardians cannot reachout on behalf of their child if they are over 18 years old. The prospective client needs to be present during the phone consultation.
Preferred Days To Be Seen
*
Monday
Tuesday
Wednesday
Thursday
Friday
No preference
Select the days you are able to have sessions on. Select all you could make work. This helps us connect you with a therapist who is available when you are.
Preferred times to be seen
*
Mornings (before 11)
Afternoons (11-4)
Evenings (5-8)
No preference
Select the days you are able to have sessions on. Select all you could make work. This helps us connect you with a therapist who is available when you are.
Therapist Preference?
*
Select
No Preference, soonest availability
Tayler Clark, LCSW
Heidi Smaradottir, LPC, MFT-IT
Ashley Trapp, LPC-IT
Ben Mattson, LPC-IT
Jamie McCleave, Clinical Intern
Preferred session environment
*
Choose one
Telehealth (virtual)
Office- In Person
No Preference
Hybrid
Primary Address
*
Line 1
Line 2
City
State
Zip Code
Country
Briefly Explain Reason for Reaching Out
*
This section helps our schedulers determine which therapist(s) could be a great match for you. Please avoid going into too much detail. However, explain what focuses you would like the therapist to have, (i.e. gender affirming, Neurodiveristy affirming & BIPOC experience affirming care)
Submit
Home
About
Work with us!
>
Clinical Therapist- IT
IC CT position
Clinical Intern
Location/Contact
>
Gallery
Office FAQs
New Adult Client form
New Minor Client form
Shorewood Office
Blog
Investment in you
Meet Us
Client Portal