Therapy Consultation Scheduling Form Page Services | Heal Therapy Clinic

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STEP 1

Easily schedule your consultation using our convenient online calendar. Choose a time that works for you.

Book My Free Consultation

Scheduled a Free Consultation with one of Licensed therapists

STEP 2

Your Full Name

Your Email Address*

Contact Number*

Which State do you reside in?*

How old are you?*

How do you identify your gender?*

Are you currently experiencing a mental health crisis?*

Yes

No

I'm not sure

What type of therapy are you looking for?*

Individual

Couples

Family Counseling

Group Therapy

Psychological Diagnosis

Why are you seeking therapy?*

Are you comfortable receiving therapy sessions via telehealth (video call or phone)?

Yes, I am comfortable with telehealth therapy

No, I prefer in-person sessions

I am open to both telehealth and in-person sessions

I am unsure and would like more information about telehealth therapy

Are you planning to use insurance for your therapy sessions? If so, could you please specify which insurance provider you will be using?

If not using insurance, are you open to discussing payment options?

Yes

Not at this time

Fill out the intake form below—we will get in touch with you within 24 hours to confirm your appointment date/ time inshaAllah

doctor sitting on desk talking to sitting woman

doctor sitting on desk talking to sitting woman

Complete your intake form...

HEAL THERAPY CLINIC

Empowering Muslim individuals & families through therapy

healtherapyorg@gmail.com

484-441-6931

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