Individual Therapy

Preferred Name

First Name

Last Name

Legal Name *

As listed on insurance.

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Is it ok to leave a voicemail at this number? *

Yes

No

Preferred communication method *

Email me.

Text me.

Call me.

Address *

Crybaby therapists are licensed in Oregon only, meaning all telehealth sessions are available exclusively to clients who are physically located within Oregon at the time of their session. Clients with out-of-state addresses may still receive services; however, they must be present within Oregon state lines during their telehealth appointments.🤠

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

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)

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

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.

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.