Concierge Application Form - Headway inSight

Let’s Begin

What you’re seeking might not be traditional therapy. It might be something more — something deeper, more personal, more intentional.

This is an application to work together in a concierge-style therapy or coaching relationship. I work with a limited number of clients at a time so that the work we do together is truly tailored to you.

If you’re ready to take the first step, complete the application below. I typically review applications within 24 to 48 hours. Watch for a response.

Name

Phone

How would you like to be contacted?

Phone call Text Email

What are you hoping to work on?

Have you worked with a therapist or coach before?

Yes No Both

Are you prepared to invest between $1,000 and $2,000 per month in your growth and well-being?

Yes, I’m ready to invest in myself. I’m interested but would like to discuss options. No, I’m not ready to make that level of investment right now.

How did you hear about me?

Anything else you'd like me to know?

This isn’t therapy as usual — and that’s the point.

You don’t need to be fixed. You just need space to be seen, challenged, and supported without judgment.

Once I review your application, I’ll reach out to schedule a short call where we can decide — together — if this is the right fit.