Jasmine Intake Form

*Please note that Jasmine only sees clients in the state of Colorado. Book a free 15-min consultation to see if you’re a fit or fill out the intake to schedule your first session!

Preferred Name

First Name

Last Name

Pronouns

Birthday

YYYY

Phone

(###)

###

####

Are you currently a college student?

Are you interested in weekly or bi-weekly sessions?

Weekly

Bi-weekly

Referral Source

Any other identity you hold you'd like to share?

Tell me a little about yourself and why you're seeking out therapy.

Have you ever done counseling before? What was your experience like?

Payment

LFH only accepts private pay clients. Sliding scale slots available by request on a first come first serve basis. If you would like to use your insurance, LFH partners with Thrizer, an online platform that allows clients to use their out of network insurance benefits for reimbursement. *Special rates for college students.*

Jasmine Intake Form

Life Force Healing Counseling & consulting