Intake request form

Thank you for your interest in receiving services through Sami Lee Counseling. To request a FREE 20-minute consultation phone call, please fill out the form below and click "Submit."

For those who may feel anxious about phone conversations, please feel free to mention this in the “Anything else you’d like me to know” section of the form. I’m happy to accommodate your preferences! :)

Thank you!

Disclaimer:

I acknowledge that this website does not comply with HIPAA regulations. By completing this form, I understand there is a risk of my information being compromised. Alternatively, I can send an encrypted and fully private email to sami@samileecounseling.com.

Name

please list your first name and the initial of your last name (e.g. Jane D.)

Age of prospective client

Email

Phone

(###)

###

####

Preferred method/location of service

In-person (Bellevue)

In-person (Monroe)

Telehealth

Briefly describe your reason for seeking counseling services

Anything else you would like me to know regarding your needs, preferences, or specific requests for counseling?

How did you hear of Sami Lee Counseling?