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Relationship Therapy

Work together to fill out this relationship therapy interest form.

Person 1 Information

Preferred Name (Person 1)

Legal Name (Person 1)

As listed on insurance.

Date of Birth
Is it okay to leave a voicemail at this number?
Yes
No 2

Person 2 Information

________________________________________________________

Preferred Name (Person 2)

Legal Name (Person 2)

As listed on insurance.

Date of Birth
Is it ok to leave a voicemail at this phone number?
Yes
No

Additional People in Therapy

________________________________________________________

Preferred communication method:
Call us.
Email us.

________________________________________________________

How will you be paying for therapy?

________________________________________________________

For the following question, please check all that apply to your degree of comfort. This list is not meant to be conclusive, but can give me a sense of how I can help.

We're interested in working on:
Have you been in therapy before?
Yes
No

________________________________________________________

The follow questions are asked to ensure that Brave Ass Scaredy Cat Counseling can honor your level of care. Thank you taking the time to share intimate info.

Person 1

Person 1: Are you taking any medications at this time? This can be for medical or psychiatric reasons. If yes, we will follow up at your first session. I take a holistic approach to your treatment and coordinate with your current care providers as needed.
Yes
No

Person 2

Person 2: Are you taking any medications at this time? This can be for medical or psychiatric reasons. If yes, we will follow up at your first session. I take a holistic approach to your treatment and coordinate with your current care providers as needed.
Yes
No

___________________________________________________________________

If Brave Ass Scaredy Cat Counseling has no availability at this time:
I'd like to be placed on my their waitlist.
I'll keep searching for a therapist elsewhere.
Telehealth (video calls) therapy sessions are limited. In-person sessions are Brave Ass Scaredy Cat Counseling's primary availability at this time.
I'm down for in-person.
I only want to meet via telehealth.

Interested in relationship therapy?

Fill out this new relationship interest form and we will be in touch in 3 - 5 business days.

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