Start your journey.

Your name *

Please enter the name of the person completing this form.

First Name

Last Name

Name of potential new client

Please enter the potential client's name here.

First Name

Last Name

What type of services are you looking for?

Please check all that apply.

Individual Therapy

Group Therapy

Sister Circle Group for Black women

Wellness coaching

Referrals for other providers

Workshops (coming soon!)

Speaking engagement

Consultation for organization or business

Appointment time *

What time would you be scheduling appointments for?

Morning, 10 - 11am

Afternoon, 2 - 5pm

**Group therapy may happen in evenings**

**Please check and acknowledge**

I acknowledge and understand that Dr. Bryanna Campbell maintains a virtual self-pay practice and does not take insurance. Full payment will be due at the time of service. Superbills can be available upon request for clients to file for out-of-network reimbursement with their insurance carrier if eligible. No in-person services are available at this time.

Yes, I understand and acknowledge this.

DISCLAIMER *

By checking this box I understand that I am only submitting information as an inquiry for services. Sending this information does NOT establish a confidential therapist-client relationship. This form will be sent to the provider and a consultation call will be scheduled to determine if current services offered are a match for your needs.

Yes, I understand and accept this.

Date

Please include the date that you are completing this form.

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