Request for 30-Minute Video Consultation- Consultation Fee Applies (All fields required)

Name

Email

Phone

How did you find out about us? How did you find out about us? Referred by a friend Referred by a provider Returning client Online search

Where are you located? Where are you located? Texas Washington State Florida

Please describe the concerns that bring you to therapy (be specific) and what you are looking for in treatment or in a provider.

Please acknowledge the following (Please check both boxes) Please acknowledge the following (Please check both boxes) I am aware that Anusree Gupta provides services virtually through video only. In-person sessions are not available.

I understand that the initial 30-minute consultation is a paid appointment ($50) and payment will be required to confirm the session.

I am aware that Anusree Gupta does not directly participate with insurance, that I will be paying the full fee at the time of service, and I can choose to submit claims to my insurance for out-of-network reimbursement.