Consulting Application

Jena's 1-on-1 Consultation Application
Please answer all questions as specifically and thoroughly as you can.

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Skype ID *

How did you hear about The Independent Clinician? *

Where are you in the process of developing your private practice? *

Describe your dream private practice. What are you hoping to achieve? *

Tell me about yourself: What is your background? Area of expertise? Geographic location? *

How can I help you? *

Complete this sentence: The consultation sessions will be a success if I am able to __________________. *

I understand that the fee for the consultation is $150 for two, 30 minute sessions. *

Yes

Submit