Stacey Uhrig

1:1 Consultation

You can get started with a consultation. My consultations are 75 minutes long (like a full regular session), but they are discounted at $75. Consultations allow you to share what is going on, allow me to offer insight and also give you a sense if we would be a good fit to work together.

My normal session rates are $200 for 75 minutes.
Consultations are limited to one per person.

Personal Information

First Name

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Last Name

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Questions / Comments

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Time Zone

Location Information

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Additional Information

Personal Data

What name do you prefer to go by

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What pronouns do you use? (e.g., she/her, he/him, they/them) or you can specify 'Prefer not to say' if you'd rather not share.

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Do you have any accessibility needs that would help you fully participate in our sessions? (e.g., physical accommodations, visual or auditory needs)

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Emergency Contact: In case of an emergency, who should I contact? (Please include name, relationship, and phone number). Is there anything I should be aware of when contacting this person?

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Did you join your family by way of adoption, kinship, or guardianship?

Yes

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If yes, at what age where you adopted? Feel free to add in any details you are comfortable with.

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Your Relationahip Status

Single

In Partnership

Married

Divorced / Separated

Widowed

Other

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Number of Children you have (if any) - list ages if you'd like

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Parents Marital Status

Single

Married

Divorced / Separated

One or more parent deceased

Never Married

Other

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Number of siblings you have (list ages if you are comfortable)

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Medical

Please select any or all that apply.

Addison disease

Dermatomyositis

Graves disease

Hashimoto thyroiditis

Inflammatory bowel disease (Crohn disease, ulcerative colitis)

Multiple sclerosis

Myasthenia gravis

Rheumatoid arthritis

Sjögren syndrome

Systemic lupus erythematosus (lupus)

Type I diabetes

Other

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If other, please feel free to describe below.

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Backstory

How did you find me?

Referral - Friend

Referral - Family

Referral - Other practitioner

Instagram

Facebook

Networking Group

Other

Podcast

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What made you schedule this call? Can you share what brought you to seek support at this time?

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What have you tried so far to overcome this challenge?

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Please select any or all that apply (occuring before the age of 18)...

Did you feel unseen or unheard at home?

Did you have a parent or caretaker who denied your reality?

Did you have a parent or caretaker who did not model appropriate boundaries?

Were you told that you can't or shouldn't feel certain emotions?

Did you live with someone who could not regulate their emotions?

Did a parent or caretaker swear at you, insult you, or put you down on a frequent basis.

Was it common for a parent/caretaker to humiliate you or act in a way that made you afraid?

Did a parent or family member not look out for you, feel close to you, or support you?

Did a parent or caretaker ever hit you so hard that you had marks or were injured?

Did you often/very often feel that no one in your family thought you were important?

Were your parents were too drunk or high to take proper care of you?

Have times in which you didn’t have enough to eat or had to wear dirty clothes?

Biological parent ever lost to you through death, divorce, abandonment, or other reasons?

Was a parent often/very often pushed, grabbed, slapped, had something thrown at her/him?

Was a parent or caretaker kicked, bitten, hit with a fist, or hit with something hard?

Did you experience being repeatedly hit or threatened with a gun or knife?

Did you witness someone else being repeatedly hit or threatened with a gun or knife?

Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs

Was a household member depressed or mentally ill, or attempt suicide?

Were you asked to keep secrets by a parent or caretaker that made you feel uncomfortable?

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Is there any other information you would like to share that you feel would help me understand your needs better? Is there anything else you think is important for me to know about you?

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1:1 Consultation with Stacey Uhrig

Stacey Uhrig

Personal Information

Location Information

Additional Information

Personal Data

Medical

Backstory