Appointments - Awakening Into Life

Please complete the following form to request your FREE, online telehealth counseling session(s).

The effective period of service availability is 30 Nov 2020 until 7 Feb 2021 (10 weeks).
Services are delivered via SimplePractice, a fully HIPAA-compliant telemental health platform.
Additional intake forms and materials will be provided when your initial appointment is scheduled.

Name *

First

Last

Email *

Your personal information will not be shared. This information is required for scheduling purposes.

Phone Number *

Your personal information will not be shared. This information is required for scheduling purposes and for emergency contact reasons.

I certify that I am a resident of Florida and will be located in Florida whenever these services are delivered.
I understand that Bradley Bemis is a Student-Intern taking part in a supervised course of study.
I authorize Dr. Teresa Bobo to participate in supervised sessions if and when needed.

When Would You Like to Meet? (Optional)

Appointments available Tues-Fri from 6pm-9pm and Sat-Sun from 11am-9pm on a first-come, first-served basis unless otherwise arranged in advance.

What Would You Like to Talk About? (Optional)

Please be aware that this form is not a secure form and the information shared is not encrypted or protected. With this in mind, please provide general rather than specific information.

Additional Provisions to Facilitate Supervision (Optional)

I am willing to have my sessions recorded for submission to supervisory staff at Walden University and to Dr. Teresa Bobo (Optional)