Name
*
First Name
Last Name
Email
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Is the address above where you are most likely to do teletherapy sessions from?
*
Yes
No
Number
*
Are you comfortable with us leaving a message identifying ourselves at the phone number you provided?
*
Yes
No
Date of Birth
*
MM
DD
YYYY
Gender
*
Female
Male
Non-Binary
Prefer not to choose
What are your preferred pronouns?
She/Her
He/His
They/Theirs
Other
Race and Ethnicity
*
Daily Availability (check all that apply)
*
Time Availability (check all that apply)
*
Who referred you to us?
*
Word of mouth (i.e. family, friend, coworker)
Therapist/Psychiatrist
Social media (i.e. Instagram, Facebook,)
Internet Search (i.e. Google)
Other
Please specify name of referral source:
*
Type of Therapy
*
Individual Therapy- Adult
Couples Therapy
Partner's gender
Female
Male
Non-binary
Prefer not to choose
What are your partner's preferred pronouns?
She/Hers
He/His
They/Theirs
Other
Have you experienced any of the following in the last 6 months? (check all that apply)
*
*If you are currently experiencing self-harm/suicidal thoughts or feel in danger, please call 911 or your local crisis emergency services for immediate help.
If seeking therapy services, I understand that Dr.Daryl does not accept insurance at this time. If seeking coaching services, I understand coaching is not reimbursable by insurance.
*
