Interest Form

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Thank you for your interest in the Brief Psychotherapy Research Program.

To request an initial consultation, please fill out the information below to the best of your ability. Once we receive your request, we will contact you via email or phone (most likely within 1 to 2 business days) to discuss next steps.

Once we contact you, we will conduct a brief phone screen to determine whether or not to move forward with a free evaluation to ascertain if your needs are best met by our services, or if you would be better served by a referral to another provider. Please note that completing the assessment does not guarantee placement with Brief.

If you are still interested in services at Brief, please fill out the following confidential information form, and we will contact you. Our aim is to serve you as quickly as possible.

If you do not wish to submit your information online, feel free to call us at 332-243-1978

Full name:

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Phone number:

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Preferred email address:

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Home address:

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Age:

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Do you have health insurance? If so, what health insurance do you have?

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How did you hear about our program?

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Brief description of why you are seeking services:

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Are you currently in individual psychotherapy?

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Yes

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We offer treatment Monday-Friday between the hours of 9:00am and 5:00pm.

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