Initial Inquiry Form for Dr. Geri Weitzman's psychotherapy practice

Greetings! Please use this form to describe to Dr. Geri Weitzman what you are looking to work on in therapy, so that she can help to determine whether her practice will be a good fit for your needs.

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What is your name (first, last)?

Which USA State/s do you live in (or which country, if non-USA)

What is your email address?
What is your phone number?
Are you looking for individual or relationship counseling?
Ages of participants in therapy

Please check off which of the following concerns you would like to be a significant focus of your therapy. If your particular concerns aren’t listed, there is a space below where you can list other concerns.

Please describe in your own words the main concerns that you are looking to work on in therapy. A few sentences is fine.

Are your sessions covered by one of the following EAPs?

Please say which other third party payor/s you are working with, if any (Insurance, Medicare, etc). There will be a space below to indicate any third party payors not listed here. If you are covered by more than one, please check each one that you are covered by.

Please list any third party payor coverage (insurance, EAP, etc) not listed above.

Which employer/s is your insurance / EAP through? (This may be different from your own employer if your coverage is via a spouse's or parent's employment)

Does your EAP / Insurance plan offer...

If someone referred you to Dr. Weitzman, please say who so that Dr. Weitzman can thank them:

Which website or forum did you hear about Dr. Weitzman's practice on?

Please use this space to ask any questions, or to let Dr. Weitzman know anything else that you feel wasn't covered above. Thanks!
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