Relationship Therapy

Preferred name of Person 1

First Name

Last Name

Legal Name of Person 1 *

As listed on insurance.

First Name

Last Name

Date of Birth - Person 1 *

MM

DD

YYYY

Phone Number - Person 1

(###)

###

####

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

Yes

No

Person 1's 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

Preferred name of Person 2

First Name

Last Name

Legal Name of Person 2 *

As listed on insurance.

First Name

Last Name

Date of Birth - Person 2

MM

DD

YYYY

Phone Number - Person 2 *

(###)

###

####

Preferred communication method *

Email us.

Text us.

Call us.

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

Yes

No

Person 2's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Have you been in therapy before? *

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 therapists at Crybaby.

I'll keep searching for a therapist elsewhere.

When meeting with my therapist, I prefer: *

In-person sessions

Teletherapy (video call)

Sometimes in-person / sometimes teletherapy

Not sure yet, let's decide later