Interested in working with me?

Name *

First Name

Last Name

Phone *

(###)

###

####

What service(s) are you interested in? *

check all that apply

Individual Therapy

Couples Therapy

EMDR Intensive (in person only)

What are you interested in addressing? *

check all that apply

Stress

Perfectionism

Anxiety

Depression

Developmental trauma

Relational distress

Preventative relational wellness

Life transition

Other

Due to licensing restrictions, I can only provide services in the state of Texas as long as you are located in the state of Texas. You acknowledge that you are located in the state of Texas and that services received will be rendered in the state of Texas. *

Yes

I understand that submission of this form and any resulting consultation communication with SQ Therapy, PLLC does not in itself initiate a therapeutic relationship between myself and SQ Therapy, PLLC. *

Yes

I understand this form is not intended to address time-sensitive matters or to receive immediate emergency support. If you are experiencing an emergency please contact 311, 911, and/or 988. *

Yes

I acknowledge the fee of $150 for individual and $200 for couples therapy for a 50-60 minute session. Furthermore, I understand that my provider does not accept insurance. If you are interested in receiving a superbill please notify Yamel Sandoval Quijano, LMFT. *

Yes