Comma Co. | SimplePractice

Comma Co. Send Message

Your info

First name

Last name

Email

Phone

Name you go by

Date of birth

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State

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Reason for care

What mental health concerns or treatment have occurred in the past?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past None of these apply

Tell me briefly about yourself and what led you to consider this call?

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Administrative

How did you hear about me?

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Client Preferences

Please add any possible availability for sessions below.

I currently see clients Monday-Thursday from 10am-4pm (last appointment is at 3pm)

Billing & Payment

I understand that sessions are $150 after the free consultation, and I’m comfortable moving forward at that rate.

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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.