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Providing virtual sessions for clients in Washington state, Idaho, and Illinois

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- Dr. Bornell Nicholson
- Melissa Nicholson
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This form is not for emergencies purposes. If you are experiencing an emergency please proceed to your nearest hospital or call 911.

All intakes will be responded to within 48 hours.

New Client Intake Form

New clients fill out the form

First Name

Last Name

My child's name (if necessary)

My child's age (if necessary)

Relationship to child (if necessary)

Phone

Birthday * required

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Whom are you seeking therapy for? *

Myself

My child

Couples

Family

Which thearpist would you like to work with? *

Dr. Bornell Nicholson, LMFT

Melissa Nicholson, MA, LMFT

Open to working with either

Fireside only holds virtual sessions. Are you well with virtual therapy? *

Yes, I can meet virtually

Will you be paying with an Insurance, that is in network with Fireside Psychotherapy? *

Yes, I have Premera of Washington

Yes, I have United Healthcare of Washington

No, I will be Private Pay (i.e., out of pocket)

Please provide a few days and times of availability

Perferred Method of Communication?

Phone call

Either email or phone call

In a few words please describe the reason you are seeking therapy services.

How did you hear about us?

Friends/Family

Professional Referral (i.e., doctor, therapist, etc.)

Internet search

Other

* Communication consent

I understand that by submitting this form I am agreeing to the risk of sending my Personal Health Information via an insecure website. I also agree to allow Fireside Psychotherapy to email, text, and phone communicate with me, which may not be secure and/or confidential.

Thanks for submitting!

Contact

Email: drnicholson.lmft@gmail.com

Tel: (509) 596-1435

Instagram

Location: Spokane, WA

In person & virtual sessions available

Schedule an Appointment

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