JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Therapy Charlotte LLC
In preparation for your first appointment, please complete the following form. The information you provide here is protected by law and held in strict confidence.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Full Name:
*
Your answer
Home Address
Your answer
Birth Date
*
MM
/
DD
/
YYYY
Current Occupation:
*
Your answer
Primary Phone Number
*
Your answer
May I leave a message?
*
Yes
No
E-mail Address
*
Your answer
May I e-mail you? (Please note: E-mail correspondence is not considered to be a confidential medium of communication)
*
Yes
No
Name of emergency contact:
*
Your answer
Phone number of emergency contact:
*
Your answer
How did you hear about Therapy Charlotte?
*
Internet search
Referred by a friend
Psychology Today Directory
Other:
Areas of Concern: Please check all that help describe your concerns or goals.
*
Career identity or planning isses
Communication
Conflict-resolution
Decision making
Depression or feeling low
Difficulty concentrating
Feeling "stuck"
Impulse control issues
Managing emotions
Perfectionism or procrastination
Problem solving
Relationship issues
Self-esteem or personal growth
Stress/Anxiety
Struggling to perform in career
Thoughts of suicide or homicide
Other:
Required
In your own words, what do you hope to get out of the therapy or coaching experience?
*
Your answer
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Therapy Charlotte.
Report Abuse
Forms
