Therapy Services Inquiry Form

two individuals intertwined icon

Thank you for your interest in receiving therapy from Liberate Psychological & Consultation Services, Inc. (Liberate). In order to best address your specific questions and goals, please complete the brief form below.

If you are experiencing a life-threatening emergency or do not feel safe, please stop here and call 911 or go to your nearest hospital’s emergency department.

Be aware of the limits of confidentiality prior to submitting this form:  If you report the abuse of a child, elder or dependent adult, and/or communicate a plan to kill yourself or someone else, these events may not be kept private.

Liberate’s policy deems that potential patients must reach out directly to inquire about services. However, if you are 16 years of age or older, your legal guardian(s) will need to reach out on your behalf.

I understand that Liberate’s policy is to provide short-term, action-oriented therapy
I understand that Liberate’s policy is to provide telehealth (videotherapy) only
I understand that Liberate provides services to residents of California or New York who report being located in California or New York at the time of the session
I understand that Liberate’s policy deems to only provide treatment for patients 16 years of age and older
I understand that Liberate does not accept insurance, but can provide me with a “superbill” to submit to my insurance company for potential reimbursement
I understand that Liberate’s policy is to deny requests for letter-writing services (legal, housing- including emotional support animals, employment, disability, citizenship, school, etc.) except for requests for letters for purposes of trans supportive medical care
Have you browsed around Liberate’s website, social media pages, etc. to get a sense of whether therapy at Liberate could suit you?
Name of potential patient
For legal guardian(s) filling out form for an underage potential patient, what is your name?
e.g., they/them, she/her
I understand that Liberate staff will reach out to me via email at the address/es I provided
Phone number of person filling out form
I understand that Liberate staff may reach out to me via text me at the number I provided if I fail to respond to their initial outreach email
Birthdate of potential patient
Recent thoughts of self-harm?
Answer Yes or No. If Yes, write approximate dates you were hospitalized and reason/s
Is the potential patient involved in any agency or circumstance which may require them to provide information about their session attendance?
Is the potential patient looking to use Medicare or Medicaid to pay for services?
I understand that completion of this form does not establish a professional relationship with Liberate Psychological & Consultation Services, Inc.
I understand that confidentiality of electronic communication cannot be guaranteed. I release Liberate Psychological & Consultation Services, Inc. from all liability from electronic communication