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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
Month
Day
Year

You agree to receive informational messages (appointment reminders, account notifications, etc.) from Kapu Waia'u Dancel & Brave Ass Scaredy Cat Counseling & Crybaby Counseling. Message frequency varies. Message and data rates may apply. For help, reply HELP or email us at kapu@crybabycounseling. You can opt out at any time by replying STOP. https://www.braveassscaredycat.com/mobilesmsterms-conditions-privacypolicy

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
Month
Day
Year

You agree to receive informational messages (appointment reminders, account notifications, etc.) from Kapu Waia'u Dancel & Brave Ass Scaredy Cat Counseling & Crybaby Counseling. Message frequency varies. Message and data rates may apply. For help, reply HELP or email us at kapu@crybabycounseling. You can opt out at any time by replying STOP. https://www.braveassscaredycat.com/mobilesmsterms-conditions-privacypolicy

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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