Fill out the short questionnaire to help us hit the ground running on our call ⬇️

Fill out the short questionnaire to help us

match you with the right therapist. ⬇️

I consent to data use described below

By submitting this form, you acknowledge our Privacy Policy and consent to being contacted. No diagnostic, clinical, or treatment information is shared beyond what is stated below.

I voluntarily authorize Alternative Solutions Counseling and Coaching, LLC to share my name, email address, phone number, and the fact that I am inquiring about therapy services with Meta Platforms, Inc. (Facebook/Instagram) for advertising measurement and campaign optimization purposes. My ability to receive services is not conditioned on checking this box. This authorization expires 12 months from today or immediately upon revocation, whichever occurs first. Revocation will not affect information already shared prior to the date we receive the revocation request. Information shared with Meta may no longer be protected by HIPAA and may be redisclosed by Meta according to its own privacy policy. Requests to revoke may be sent to [email protected]

Fill out the short questionnaire to help us match you with the right therapist. ⬇️

Fill out the short questionnaire to help us

hit the ground running on our call ⬇️

What is your gender?

How old are you?

What led you to consider therapy today?

(Please go beyond saying "depressed" or "anxious" - share how this is impacting you on a day to day basis)

What are some of the things you are struggling with?

How long have you ben experiencing these struggles?

Have you been in therapy before?

Which state are you in?

You have completed the questionnaire!

Let's get you scheduled for a complementary 15-minute consultation with one of our team members.