Karascope Counseling | SimplePractice

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

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Personal pronouns

Administrative

Referral source

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Thank you for reaching out to explore working together. This brief questionnaire provides helps each of us prepare for the call, by giving you an opportunity to specify any concerns or needs prior to our chat, and by giving me an idea of what might be helpful to share with you. Looking forward to connecting with you - Kande

Free consultations are typically done by phone, unless video is requested. Video calls are conducted through Karascope Counseling's secure client portal. Do you have a preference for phone or video?

Phone (default for free consultations prior to beginning work together) Video (By request for 15-minute consultations and all other services.) In person (For those ready to begin services. Not an option for 15-minute consultations)

Client Preferences

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, questions about style or treatment options, etc.

Limited to 600 characters

Reason for care

Please let us know if you have particular questions or a type of information that would be helpful to you as you determine your best fit with a therapist.

Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.