Right Fit Questionnaire
Adult Teletherapy

Is Online Therapy with Dr. Weeks Right for You?

This brief (5-question) anonymous questionnaire respects your time and helps determine if services align with your needs – before scheduling a consultation.  

If this is likely a good fit, you will be automatically connected to my secure calendar to schedule a free 15-minute phone consultation. During the consultation I answer additional questions to help determine whether working together aligns with your needs and situation. 

If we agree that working together is a good fit, you receive an invitation to my EHR client portal to complete initial paperwork with form of payment to schedule an appointment. The intake and individual therapy (60 minutes) rates are $250, $200 (45 minutes), and extended sessions are pro-rated in 30 minute increments. Fees are due at the time of the appointment with valid form of payment maintained in the EHR client portal. 

Why are you considering therapy?

(Check all that apply)

 
 
 
 
 

Are you atleast 18 years old?

 
 

During appointments will you:

  1. Be in a PsyPact participating state?

  2. Have a stable internet connection?

  3. Have a device with working camera?

  4. Remain in a private, confidential, stationary location (not driving or in a public space)?

  5. Avoid multitasking and using intoxicating substances?

 
 
 

I understand this practice is private-pay, Out-Of-Network, and does not accept Medicare. I’m aware that a form of payment is needed to schedule appointments, and services are billed at the time of the appointment. 

By scheduling a consultation, I acknowledge that fees for services are not a financial burden. 

 

 
 
 

What matters most to you right now?

(Choose up to 3)

 
 
 
 
 
 
 
 
 

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