Intake Request Form — Jenny Usselman Counseling, PLLC

Request an Intake

Thank you for your interest in seeking counseling services through Jenny Usselman Counseling! To request an initial appointment, please fill out the intake request form and click “Submit.” I will contact you within 2-3 business days to follow up. If you have any additional questions, please feel free to email me at jenny@jennyusselmancounseling.com

Name

First Name

Last Name

Age

Age of the prospective client

Phone Number

Type of Service Requested

Individual Therapy

Couples Therapy

Family Therapy

Parent Coaching

Preferred Location of Service

In-person (Maple Valley, WA)

In-person (Fall City, WA)

Telehealth

No preference

Please briefly describe current reasons for seeking counseling

Anything else you would like me to know regarding your needs, preferences, or specific requests for counseling?

How did you hear about Jenny Usselman Counseling?