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Rachel Baumann

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Tel: 203-533-1252

Email: fairfieldtherapy@gmail.com

New Client Consultation Form

Will this appointment be for you or are you making a referral for someone else?*

Myself

A minor child under my care

An adult under my care

I am making a referral for someone

My partner and me

My family and me

Other

First name

Last name*

Email*

May I send you emails?*

Yes

No

Client Information

If you are not the client, please answer the questions below regarding the client. I will be in touch with you soon to schedule your free 15 minute consultation.

Preferred Pronouns *

What is the name(s) and age(s) of the person seeking care?*

What service(s) are you seeking?*

Individual therapy or coaching

Family therapy

Couples work around OCD/Anxiety

Neuro-affirming Psychological Assessment

Other

What are the primary reason(s) that you are seeking services for?*

Anxiety

OCD

Body-Focused Repetitive Behavior

Trauma

Neuro-affirming Psychological Assessment

Learn more about my neurotype

ADHD and Executive Functioning

Autism

Relationship concerns

Life transitions

Eating Disorder

Grief

Other

Is there anything else you would like me to know before our initial consultation? Please include the best days/times that generally work for a call.

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