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Let's Explore Whether Therapy Is the Right Fit.

Private Therapy Application

Private therapy at Alternative Healing is intentional, personalized, and collaborative.

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Before scheduling a consultation, I invite prospective clients to complete this brief application. Your responses help me understand your general goals, confirm service eligibility, and determine an appropriate next step.

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Please keep responses general. Detailed clinical information can be discussed through a secure intake process.

Basic Information
What state will you be physically located in during sessions?
Type of support:
Readiness & Goals
Which of the following best describes you? (Select all that apply)
Emotional & Nervous System Awareness
Are you currently in crisis or experiencing active suicidal thoughts?
Yes
No

If you are currently experiencing active suicidal thoughts or feel at risk of harming yourself, private outpatient therapy is not the appropriate level of care at this time.

Please seek immediate support through one of the following resources:

• Call or text 988 (Suicide & Crisis Lifeline – U.S.)

• Call 911 or go to your nearest emergency room

• Contact your local crisis center

If you are outside the U.S., please contact your local emergency services.

Your safety matters. Reaching out for immediate su

Commitment & Structure
My rate for 60-minute individual sessions is $150. I am currently an out-of-network provider and DO NOT accept insurance. I am able to provide a superbill for possible reimbursement. Are you comfortable investing in out-of-pocket services?
Yes, I understand services are private-pay
I would like to explore other options

Created by Dr. Ernesha Smith

Holistic Therapist • Somatic Practitioner • Integration Guide

This space exists because healing deserves to feel safe, spacious, and human.

You don’t have to rush your becoming.

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