Service Request Reduced Fee — ODDESTY K & ASSOCIATES

Request Therapy Service.

PLEASE BE ADVISED THIS IS NOT THE CORRECT FORM TO REQUEST FREE THERAPY SERVICES WITH OUR CLINICAL INTERN. IF YOU ARE SEEKING FREE THERAPY, PLEASE USE THIS LINK INSTEAD: FREETHERAPYSERVICES

IF YOU ARE SEEKING TO USE INSURANCE FOR THERAPY SERVICES, PLEASE DO NOT COMPLETE THIS FORM. INSTEAD, CLICK THE LINK BELOW TO BE REROUTED TO THE CORRECT FORM. THERAPYUSINGINSURANCE

At this time, our therapist only have telehealth availability. The in person schedule is filled for the remainder of the year.

Please complete the form below to request to start therapy services. Please note, that you may be asked to complete a separate form if more information is needed, in order to determine if the work we do is aligned with your therapy needs.

Name

First Name

Last Name

Phone

(###)

###

####

Age

State of Residence

Does Your schedule allow for you to attend weekly or bi-weekly therapy Between The hours of 8am - 3pm, or will you need evening appointments?

Briefly Explain Your Need For Therapy

Select A Therapist

Our Reduced Fee Services Are Based on Income and Need. Please indicate Which Tier You Would Be Able To Commit To For Therapy Services. Please note that in order for us to continue providing reduced fee therapy, we depend on your honesty in terms of what you can pay. We cannot guarantee that a slot will be available in your selected tier. You may have to be placed on a waiting list for you desired tier.

Are you currently experiencing suicidal thoughts/ideations?

If you are having a mental health emergency or crisis, please call 988 or report to your nearest emergency room. Note, that getting in to see a therapist can sometimes take up to two weeks. We are unable to respond to mental health emergencies for individuals who are not established clients.

Have you been hospitalized for mental health concerns within the last 5 years?

Please explain

Are you currently experiencing any homicidal thoughts/ ideations?

I understand that by using the reduced fee therapy program, I am opting out of using insurance and that my insurance will not be billed for these services, as the providers apart of this program do not accept insurance. I understand that I am responsible for payment at the time of service. I also understand that I have a right to terminate services at any time, for any reason.

I understand

How did you hear about us?

Request Therapy Service.

You belong here. ♡