Empowerment Session Intake Form

Name *

Email address *

Message *

What type of support are you seeking? *

Please select at least one option.

Credentialing support

Billing assistance

Regulatory compliance guidance

General consultation

What is your primary area of practice? *

How many years have you been in practice? *

What are your preferred methods of communication? *

Please select at least one option.

Email

Phone

Video Call

In-person

Please describe any specific challenges you are facing in your practice. *

What is your availability for a session? *

Please select at least one option.

Weekdays

Weekends

Evenings

Mornings

How did you hear about therassistant? *

Please confirm that you are not a robot.

Therassistant