Request to Work with Jake This form is for potential clients seeking to be contacted when space opens up with Jake Lohwater, LCSW. Please fill out this form completely. Completion of this form indicates your desire to be placed on a waitlist and in no way starts or guarantees a therapeutic relationship. At this time, we are only offering telehealth appointments, so all appointments are 100% virtual.Name First Last Phone Email Pronouns I am seeking therapy in: Golden, CO location Fort Collins, CO location note: At this time, all appointments are 100% virtual for both locationsI am seeking therapy for: Individual Therapy Couples Therapy EMDR Therapy Nature Therapy Life Coaching Others Please briefly describe your reasons for seeking therapy at this time.My availability for 50 minute sessions is: Weekday Mornings (between 10am-12pm) Weekday Afternoons (between 1pm-3pm) My payment method will be:Self PayJake Lohwater is an out of network provider and not in-network with any private insurance. There are numerous advantages to working with an out-of-network therapist. Such an arrangement offers privacy, freedom of choice in selecting the therapist you wish, and freedom from insurance-related restrictions such as limits on session frequency and the treatment duration. A psychiatric diagnosis is required for insurance reimbursement, which may become part of your permanent health record. If your insurance plan includes out-of-network coverage, therapeutic services may be partially reimbursed by your insurer.How did you hear about Jake Lohwater?Please check to indicate understanding of the following: Waitlist times vary and it may take several months to receive contact. I am agreeing to be emailed when a spot opens up. I understand that completion of this waitlist request form does not indicate a therapeutic agreement with Jake Lohwater. If I do not hear from someone in 3 months’ time and I am still looking for a therapist I may complete this form again. Anything else you'd like me to know?Add me to your mailing list Add me to your mailing list Anti Spam | What is 1 + 1? Your privacy is important to us. We’ll never share your information.
