Schedule an Appointment

top of page

Serving clients in-person in Spokane and Virtually for clients in Washington state and Illinois

Home
About Us
Our Therapists
- Dr. Bornell Nicholson
- Melissa Nicholson
Services
FAQs
Schedule an Appointment
More

Use tab to navigate through the menu items.

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

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

How would you like to meet for sessions? *

In Person

Virtually

Open to either

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, and phone communicate with me, which may not be secure.

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

bottom of page