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Consultation Request Form

Please fill out the following form.

*Please note that we are accepting clients age 25 and older. Clients must reside in either Fl, Ga, Tx.*

First name

Last name

Email

Date of Birth

Telephone number where you can be reached for consultation

Have you attended therapy in the last 6 months?

No

Yes

Who referred you to us?

Please select the state you reside in

Are you interested in individual or couples therapy? *Please note that couples counseling and family therapy is offered for in-office only. Please do not select couples or family if you are not available for in-person sessions.*

In-person (office) or Telehealth (virtual)?

Have you experienced any of the following in the last 12 months?

Thoughts of suicide

Self-Harm behaviors (cutting or attempt to harm self)

Hospitlzation for mental health issue

violence, physical abuse, sexual assault

Substance abuse issues

Traumatic event

Experienced a loss including a death of a loved one and/or divorce/breakup?

None of the above

Please leave the best time to contact you for a telephone consultation

If seeking therapy services, I understand that Dr. Antionette is not accepting insurance at this time? *with the exception of Florida residents that have Aetna insurance

No

Yes

In order to make sure you are a good fit, please tell us why are you seeking therapy at this time?

Initials

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

COPYRIGHT © 2018 by Seeking Solutions of South Florida, LLC

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