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: Online/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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Full Legal Name *

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Last

Gender *

Your City *

Birthdate and Age *

State *

Country *

Cell Phone *

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

Email *

Have you participated in psychotherapy before? What type of therapy was it? *

Have you participated in hypnotherapy, 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: *

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. *

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

How did you hear about Paige? *

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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): *

If you live in Texas, and want to use insurance to help cover therapy costs, the information you provide below will allow me to check your deductible and benefits before we speak. Please provide the name of your health insurance company. *

Please provide your insurance ID, and your group ID number listed on your insurance card. *

Please provide YOUR address listed with your insurance company. *

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

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

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