Name *

First Name

Last Name

Phone *

Sasha will only call you after confirming with you via email on consultation time.

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I understand: *

That Sasha is Licensed to provide counseling services to residents of Idaho, Montana, and Washington only.

Sasha offers telehealth for those residing outside of Sandpoint, Idaho.

I can receive non-counseling related services in any state.

If I choose to use private insurance, a diagnosis is required to be submitted to my insurance company. I understand they will have access to my therapy records.

Terms of use *

via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Submit " you agree to hold Equilibrium Counseling/Sasha Krotova, LCSW harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

Yes, I want to submit this form.