Concierge Therapy Inquiry Form Name * First Name Last Name Email * What are your top three goals for this program? * What are your top three daily struggles? * On a scale from 1-10 how ready are you to dive in? * How do you learn best? * What would your ideal program look like? (i.g.: 1:1 session frequency, unlimited secure messaging, daily phone calls, community-based supports, case management) TOPIC (click as many as you need) * What topic is your #1 focus? Wellness for Couples Healthy Relationships Improving Daily Life with Anxiety and/or ADHD Independent Living Skills A Mix Finances * Financial wellness is very important when considering concierge therapy- what do you feel is your weekly financial range for this? Jump start- $700-$1000 I'm ready-Up to $1300 Let's do this- Up to $1600 Give me the most support possible SUPPORT AREAS (click as many as you wish) * What type of support are you seeking? 1:1 Sessions Online Attachment Course Yoga & Meditation Challenges Community Support Secure Messaging Online Couples Wellness Course Thank you! Kali will be in touch soon. 3-month+ individualized programming
