Name
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First Name
Last Name
Email
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Phone
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(###)
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####
How would you like us to contact you?
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Phone
Email
No preference
Please provide the name, phone number and email address of the other consenting caregiver. If you have sole custody, please type N/A.
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How did you hear about Ensemble Therapy?
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Why are you seeking therapy for your family?
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Check all that apply.
Abuse, Emotional/Physical/Sexual
Adjustment to Change & Transitioning
Attachment, Adoption, Neglect
Attention Deficit/ Hyperactivity Disorder (ADHD)
Anger Management
Anxiety, Worries
Behavioral Issues, School Behaviors
Conflict Resolution, Communication
Coping Skills, Big Emotions
Depression
Divorce, Separation, Blending Families
Friendship, Relational Aggression
Grief & Loss
LGBTQI+
Parenting, Discipline & Setting Boundaries
Self-Esteem
Trauma and Post-Traumatic Stress Disorder (PTSD)
Parent Coaching
Occupational Therapy
Parenting Book Club
Parenting Support Group
CPRT (Child Parent Relationship Therapy)
PCIT (Parent Child Interaction Therapy)
What is the client's age?
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What are the client's pronouns?
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she/her
she/they
he/him
he/they
they/them
not listed here
I understand that if I am concerned about my child inflicting harm to themself or others, then I will reach out to one of the crises resources on our FAQ page.
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Ensemble Therapy has a waitlist for services and does not provide crisis services.
Yes I understand, I do have concerns.
Yes I understand, I do not have concerns.
Please check the caregiver's current marital status.
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If the child’s caregivers are divorced then a copy of the complete divorce decree MUST be provided to Ensemble Therapy before the family will receive services.
Married
Separated
Never Married
Divorced
Widowed
Domestic Partners
Additional information you'd like us to know
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Are you interested in in-office sessions or teletherapy?
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Specific clinicians may/may not have availability based on your office preference.
Telehealth
In-Person at our office at 5802 Berkman Dr, Suite A, 78723
In-Person at our office at 4210 Spicewood Springs Rd, Suite 203, 78759 (Accessibility note: This office is on the second floor with only stair access, no elevator option yet)
No preference
Are there any accommodations your family might need for either in-person or virtual sessions?
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Which type(s) of appointments are you interested in?
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Individual
Family
Appointment Availability
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We do our best to accommodate our clients' complex scheduling needs. Please note that Fridays, Saturdays, and after school times are the most requested times, hence we are busiest. If you have more flexibility in your schedule, the sooner we'll be able to get you onto the schedule.
Please list all possible OPEN availability below.
Which professional are you most interested in working with your family? (All therapists do have a waitlist so we will reach out to you with estimated availability)
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Check all that apply.
Kate Curran Mire, SSP, LSSP, NCSP - Parent Coaching only
Kim Strickland, OTR, ATP, M.S. - Occupational Therapy only
Ashley Hembrock, LPC Associate, NCC
Ben Kinsey, LCSW
Colleen Turner, LCSW, TBRI® Practitioner
Jami Lewis, LPC Associate
Jillian Young, MS, LPC
Kaylyn Evans, MA, LPC, NCC
Leah Gilbert, MEd, LPC-S, NCC
Maira Torres, LMSW
Meagan Butler, LPC, TBRI® Practitioner
Rachel Esparza, LPC Associate
Rebekah Hess, LPC
Royal Kelly, LMSW
Sarah Kelton, LPC Associate, RYT200
Shawna West, LPC, NCC, ASDI
Sheila Wessels, MEd, LPC-S, RPT-S™
Suzanne O'Brien, LPC, CCST
No preference, first available
I understand that if there is a legal custody arrangement in place that requires consent from both caregivers for psychological and mental health services, we cannot add you to our waitlist unless both parties are in agreement.
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Yes, we are in agreement to consent to services.
No, I will reach back out once I have confirmation.
Would you like to be added to our monthly newsletter?
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Yes
No
All therapists at Ensemble Therapy are private pay, which means we are not in-network with insurance providers. You may wish to consult with your insurance company to inquire about reimbursement for therapy services. We will provide you with monthly receipts, if you request. Reimbursement is considered a matter between you and your insurance carrier. If you would like our handout about seeking information from insurance companies about reimbursement, please check yes below.
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Yes
No
When you push submit on this form, you'll be taken to our calendar to schedule your 15 minute consultation call. Please wait 5-10 seconds to be redirected.