*Please note that any of the information you submit below is not HIPAA protected, and joining the waitlist is not the same as entering into a counseling relationship or consent to treatment*

Preferred Name *

First Name

Last Name

Age *

Email *

Phone *

(###)

###

####

What would you like to address in therapy together? *

Is my private pay rate of $125/session okay, or would you like to use insurance? *

If insurance, what insurance do you have?

Please check all current symptoms *

Suicidal ideation (passive, with no thoughts of plans or means)

Suicidal ideation (with plans or means)

Hopelessness

Mania

Addiction

ADHD

OCD

Disordered Eating

Active Trauma Situation (including traumatizing living or financial situation)

Self-Harm

none of the above

Do you want weekly or biweekly sessions? *

Do you want in-person therapy, online therapy, or no preference? *

Thank you for joining my waitlist!

I have no true estimated time of accepting you and recommend reaching out to the referrals above while waiting.

I reach out to each person on the waitlist on a first-come, first-serve basis and move on to the next person if I do not hear from you in 24 hours.

We will schedule a consultation once I reach out to you and determine that we'd be a good fit. I may refer you to another provider if I determine that you'd be better suited with someone else.

If at any time you’d like to be removed from my waitlist, simply email me and I will do so.

Location

1452 Hughes Road Suite 200
Grapevine, Texas 76051

Virtual Therapy - All of Texas

Hours

Monday – Friday
10 am - 5 pm

By Appointment Only

Contact

admin@rachelacounseling.com
(214)-494-1612

Good Faith Estimate