Name *

First Name

Last Name

Client full/legal name (if different):

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Type of service requested:

Individual Therapy for Adult, age 18+

Location Preference (this section will be updated as soon as other options become available): *

Online

Will you need services provided in another language? *

Yes

No

What days work best for you? (We will do our best to accommodate your preferred day/time)

Monday

Tuesday

Wednesday

Thursday

Friday

What time of day works best for you? (We will do our best to accommodate your preferred day/time) *

Morning 9am-12pm

Afternoon 12pm-5pm

Evening 5pm or later

Other

Residence *

By filling out this form, you understand that I must be licensed to practice in the state where you are physically located when services are provided. Please select the state in which you are physically residing:

Ohio

Illinois

Other

How did you hear about us? *

Psychology Today

Therapy for Black Girls

Word of Mouth

Google

Instagram

TikTok

Healing Through Melody Website

Other

*Note: My therapy services are delivered in partnership with Rise Counseling Group. All inquires are handled through the administrative staff at Rise - then forwarded to me. Please direct any questions/ concerns to hello@risecounselinggroup.com upon filling out the form above.

Name *

First Name

Last Name

Contact Number *

(###)

###

####

Date of the Event

MM

DD

YYYY

Time of Event

in EST

Hour

Minute

Second

AM PM