Individual TherapyInterested in one-on-one therapy? Fill out this new patient interest form and we will be in touch in 3 - 5 business days.We can't wait to cry with you. Preferred Name First Name Last Name Pronouns Legal Name * As listed on insurance. First Name Last Name Date of Birth * MM DD YYYY Email * Phone (###) ### #### Is it ok to leave a voicemail at this number? * Yes No Preferred communication method * Email me. Text me. Call me. Address Address 1 Address 2 City State/Province Zip/Postal Code Country How will you be paying for therapy? * OHP (CareOregon) Kaiser (with pre-authorization) PacificSource Moda Out-of-network reimbursement superbill (Pamela only) I'll pay out-of-pocket. If you do not have your physical OHP card, please provide your OHP ID Number: Are you covered by a secondary health plan? i.e. insurance through work, school, parents, etc. I'm interested in working on: * Please check all that apply to your degree of comfort. This list is not meant to be conclusive, but can give us a sense of how we can help! Depression Anxiety Bipolar disorder Schizophrenia Obsessive-compulsive disorder (OCD) Post-traumatic stress disorder (PTSD) Eating disorders (e.g. anorexia, bulimia, binge eating disorder) Personality disorders ADHD Work-related stress or burnout Life transitions (e.g., separation, retirement, becoming a parent) Grief and loss Chronic illness or pain management Caregiver stress Marital or couples conflicts Family conflicts or dysfunction Infidelity/ betrayal Communication issues Intimacy concerns Low self-esteem Body image issues Identity concerns and exploration (e.g., LGBTQ+ identity exploration, racial or cultural identity) Alcohol or drug abuse or addiction Gambling addiction Internet or gaming addiction Childhood abuse or neglect Domestic violence Sexual assault or abuse Witnessing traumatic events Emotional eating Body dysmorphia Disordered eating patterns Insomnia Nightmares or night terrors Sleep-wake disorders Difficulty controlling anger Aggressive behavior Meaninglessness or purposelessness Existential crises Mortality concerns Parent-child conflicts Parenting challenges or concerns Family planning or fertility issues Career dissatisfaction or indecision Workplace conflicts Academic pressures or performance anxiety Gender exploration or transition support Gender affirming letters Coming out shame with family Discrimination or oppression Acculturation or immigration stress Societal pressures or expectations Impulse control issues Behavioral addictions (e.g., shopping, hoarding) Sexual dysfunction Intimacy concerns or avoidance Asexual acceptance and exploration Exploring needs/wants Setting boundaries and standing up for yourself Learning to say no with grace Other... (please describe in the summary box below) Please share a brief summary of what brings you to therapy. Have you currently or recently had suicidal thoughts? * We ask so we can set you up with an appropriately skilled clinician. Have you currently or recently engaged in self harm? if yes, please share. (such as burning, scratching, cutting, hitting self) * We ask so we can set you up with an appropriately skilled clinician. Have you been in therapy before? * Yes No Are you taking any medications at this time? (for medical or psychiatric reasons) * If yes, we will follow up at your first session. We take a holistic approach to your treatment and coordinate with your current care providers as needed. Yes No What is your general availability for scheduling? Therapist Preference * Pamela Ganem Kim Wallace Stewart (waitlist only) Cam Ericksen Frankie Forrester Griffin Smith Kennedy Hanson Corinne Nightingale Katya Stark Any How did you find your preferred therapist? * Ex. Word-of-mouth, Psychology Today, Crybaby.care, Google Search, etc. If your preferred therapist has no availability at this time: * I'd like to be placed on my preferred therapist's waitlist. I'm open to seeing a different therapist at Crybaby. I'll keep searching for a therapist elsewhere. How did you hear about Crybaby? * In-person therapy sessions are limited. Telehealth (video calls) are Crybaby Counseling's primary availability at this time. * I'm cool with Telehealth. I only want to meet for in-person sessions. Any questions or anything else we should know? Thank you! We’ll be in touch in 1 - 3 business days.
