Request a Session

Thank you for taking the time to fill out this form. You will receive a reply within 48 hours.
If you do not receive a reply, something may have gone wrong with submission.
In that case, please email Paige directly: Paige@paigebartholomew.com.
*Please note: Phone therapy is not an appropriate source of support if you are currently suicidal, or if you have ever been diagnosed with psychosis, delusions, hallucinations or a personality disorder.
In these cases, one-on-one psychotherapy in the office is the most appropriate setting for receiving help.

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Name *

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Last

Age *

Your City *

Cell Phone *

State *

Country *

Email *

Time Zone (Example: "UTC-6" or "Central Time)) *

Have you participated in counseling before? *

Have you participated in spiritual or energy healing before? *

Provide information on your primary concern. Please be very specific: *

What are your goals for therapy? What do you hope to heal, learn or achieve? *

In the past, what strategies have you tried to heal or improve your main problem or concern? What has worked best? What hasn't worked well? *

Are you a survivor of physical, emotional or relational trauma? Please give details: *

How did you hear about Paige? *

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Have you ever been diagnosed with depression, anxiety, OCD, bi-polar, or a personality disorder? Have you ever experienced psychosis, delusions or hallucinations? Please list your diagnoses. *

What is your ideal time of day for session scheduling? (We may be able to accomodate, but please know that availability is limited.) *

Do you have a religious or spiritual view or support system? Please describe: *

On a scale of 1-10, how would you rate your readiness to delve deeply and bravely into your core issues? (1 = unsure, 10 = determined): *

What else would you like for me to know about you? *

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