Contact Light of Awareness Somatic Psychotherapy | Light of Awareness Somatic Psychotherapy

First & Last Name*

Your Pronouns (she/her, he/him, they/them)

Birthdate *

Your email*

Phone Number*

I am not currently accepting clients whose main areas of focus are: Major Depressive Disorder, Complex Trauma (when trauma has been pervasive, throughout the lifespan), personality disorders, crisis management, suicidality or self-harm, active addiction, recent grief & eating disorders. [If some of these issues arise in the course of our work, we can address those areas I have training in. However, I am gearing my practice towards other main focus areas (see below)] Please answer the below question honestly, as I'd like you to find the best therapeutic fit:*

The above listed focus areas are NOT my main areas of therapeutic focus

The above list includes my main areas of therapeutic focus, so we are not a good fit to work together

THERAPEUTIC FOCUS AREA: Which of the below options are your main areas of therapeutic focus? You MUST choose at least two (due to my form's limitations)

enhance self care, happiness & self-esteem

personal growth & self-actualization

reduce stress & increase self-care

improve boundaries

improve communication

heighten attunement to self and emotional self-awareness

increase body awareness and ability to follow the body's wisdom

connect to inspiration and intuition

support greater spiritual connection

support navigating and clarifying a life transition

increase fulfillment in my life path

increase insight into my patterns/wounds to create a loving relationship with self

get support with somatic symptoms, and working with held energy and emotion in my body (please briefly describe each somatic symptom in the field below)

process one or a few isolated traumatic incidents to bring safety, empowerment, nervous system regulation, and completion (please give me the "headline" of each incident in the field below to briefly describe it)

heal attachment wounding

Please describe any somatic symptoms or give me the "headline" of any traumatic incidents you are seeking support with:

When are you able to meet? You must check at least TWO boxes below (due to my form's limitations)*

Mondays (virtually) between 10:30am-1 pm

Mondays (virtually) between 1-5 pm

Tuesdays (virtually) between 10:30am-1 pm

Tuesdays (virtually) between 1-5 pm

Thursdays (virtually) 10:30am-1 pm

Thursdays (virtually) between 1-5 pm

Fridays (virtually) between 10:30am-1 pm

No other options work for me except the one I checked

None of the listed times, so we are not a good fit at this time

I am interested in:*

Weekly ongoing therapeutic support

Twice a month ongoing therapeutic support

Short term therapy (3-8 sessions)

What is your experience with somatic work?*

Beginner: It's hard for me to know what I'm feeling and to sense how those feelings show up in my body

Intermediate: I'm good at noticing my body's signals, feelings, and needs, but want help going deeper

Advanced: I have had training and practice in sensing how my emotions live in my body and following my body's impulses and signals to find healing, expression, regulation, and empowerment

How will you be paying?*

Pacific Source [not OHP plan]

OHP through Care Oregon or Health Share

OHP Open Card or Fee For Service [FFS]

Regence Blue Cross Blue Shield (I take a limited number of clients with this insurance)

Aetna (I take a limited number of clients with this insurance)

Out of pocket ($150-$185 sliding scale)

I have out of network benefits on my insurance plan

If you plan to use insurance, I can check your benefits and let you know if I can provide you with services and if there will be any cost to you. Please let me know the following (if you're comfortable sharing): The name of the insurance company that handles your Behavioral/Mental Health Care (often located on your insurance card). IF YOU HAVE OHP, please specify who handles your behavioral healthcare [ex: Care Oregon]:

Your insurance ID number, and group number if you have one:

Your insurance health plan customer service phone number on the back of your card

If you are an Open Card/Fee for Service [FFS] member (a type of OHP), please give me your social security number so I can check your benefits. If you'd prefer not to enter it, call and leave it on my confidential voicemail at: 619-289-7604

Have you ever been diagnosed with a mental health condition? If so, please briefly describe:*

Have you ever been hospitalized for mental health concerns? If so, please briefly describe:

Have you ever been arrested or incarcerated? If so, please briefly describe:

Do you take any mental health prescription medication? If so, please describe what you take, for which diagnosis/symptoms you take it, and for how long, and whether it is effective/supportive:

What issues are you wanting help with? What is your desired outcome of therapy?*

Contact

New Client Questionnaire

Thank you so much for taking the time to fill this out!

I will get back to you soon, and if it seems like we may be a fit, the next step will be a free 15-30 minute virtual consultation.

**If form wont submit, go back and ensure you filled out all the required fields indicated with a * next to the question, and that you chose two options in the questions that indicate you must do that.**

If you are interested in starting therapy with me, please fill out the below questionnaire as the first step!

Contacts

Virtual Psychotherapy Telehealth Services Available in Oregon (for Oregon Residents Only)

Consulting Services Available Virtually Worldwide