New Client Inquiry - Leslie Simmons, LCSW

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PRIOR TO COMPLETING THIS FORM PLEASE TEXT 512-660-8006 to request the availability of my services. After confirmation, please complete this form.

* indicates required field

Client Name:*

Age:

Name of parent(s) or guardian (if client listed above is under 18):

Email:*

Okay to email?

Yes No

Cell number:

Okay to text?

Yes No

Please check method of payment:

I plan to pay cash/credit card or check
I plan to use my HSA/FSA account

Please check primary fields of concern:

depression anxiety self harm relationships LGBTQ school/behavior/academics divorce/custody addiction grief/loss chronic illness sexual/physical abuse domestic violence other

If you checked "other" please describe or feel free to leave any additional information which might be helpful:

I do not work with those suffering from active addiction or those families needing counsel on legal matters pertaining to custody disputes/contested divorce involving children or court ordered counsel.

Have you ever been hospitalized for mental health reasons?

Yes No

What is your preferred session time?

Thank you very much for reaching out! Please feel free to email or text any questions. lcslcsw@gmail.com or 512-660-8006 (text only).

If you feel unsafe or you are in an emergency situation, please call 911 or go to the nearest emergency room.

Leave this field empty

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