Preferred name of Person 1
First Name
Last Name
Legal Name of Person 1
*
As listed on insurance.
First Name
Last Name
Pronouns - Person 1
Date of Birth - Person 1
*
MM
DD
YYYY
Email Address - Person 1
*
Phone Number - Person 1
(###)
###
####
Is it ok to leave a voicemail at this phone number?
*
Yes
No
Person 1's Address
*
If you currently don't have an address, just fill in the required address boxes with your last address.
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
Pronouns - Person 2
Date of Birth - Person 2
MM
DD
YYYY
Email Address - Person 2
*
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
*
If you currently don't have an address, just fill in the required address boxes with your last address.
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Names, ages, email addresses, and phone numbers of others that will be joining in session.
[First Name] [Last Name], [Pronouns], [Age], [Email Address], [Phone Number], [Address]
What is the structure of your relationship?
*
If you do not have your physical OHP card, please provide your OHP ID Number and the name of the person associated with OHP coverage:
We're 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.
Communication Problems: Difficulty in expressing feelings, needs, or concerns; frequent misunderstandings; or breakdowns in communication.
Trust Issues: Betrayals such as infidelity, lying, or broken promises that have damaged trust within the relationship.
Intimacy and Sexual Issues: Differences in sexual appetite, incompatible desires, or historical trauma hindering physical closeness. Kink negotiations.
High Conflict: Frequent arguments, unresolved conflicts, or patterns of escalating disagreements.
New to Non-monogamy: Preparation to open your relationship with intention.
Issues related to non-monogamy: Jealousy support, Exploring different desires in relationship structure, moving from hierarchical to non hierarchical dynamics, working on issues in your non-monogamous relationships, rekindling connection in LTR’s in the face of NRE.
Financial Disagreements: Differences in financial values, spending habits, or conflicts related to money management.
Parenting Challenges: Disagreements or conflicts related to parenting styles, decisions about raising children, or blended family issues.
Emotional Distance: Feeling disconnected, emotionally distant, or unfulfilled in the relationship.
Life Transitions: Challenges related to major life changes such as job loss, relocation, retirement, or becoming empty nesters.
Cultural, Racial, Religious Differences: Conflicts arising from differences in cultural backgrounds, traditions, religious beliefs, and interracial coupling.
Family Planning: Struggles related to infertility, decisions about starting a family, decisions about adoption, or disagreements about family planning.
Substance Abuse or Addiction: Issues related to substance abuse, addiction, or recovery that impact the relationship.
Mental Health Concerns: Challenges related to mental health issues such as depression, anxiety, bipolar disorder, or other conditions affecting one or both partners.
Boundary Issues: Difficulty setting or respecting boundaries within the relationship, leading to feelings of intrusion or neglect.
Jealousy and Insecurity: Feelings of jealousy, insecurity, or possessiveness that impact the relationship dynamics.
Role Expectations: Conflicts or disagreements related to roles, division of labor, expectations, or responsibilities within the relationship.
Loss or Grief: Dealing with significant losses, such as the death of a loved one, and navigating grief together.
External Stressors: External pressures such as work stress, extended family issues, or societal pressures impacting the relationship.
Pre-Uhauling/Pre-marital/commitments: Addressing concerns before big commitments, exploring compatibility, or seeking guidance on building a strong foundation for the future.
Conscious Uncoupling: Help navigating separation with care and support.
Surprise Me. (Please describe in the summary question below.)
Please share a brief summary of what brings you to therapy.
This helps us match you with a therapist who can help you best.
Have you been in therapy before?
*
Yes
No
What is your general availability for scheduling?
Therapist Preferance
*
Pamela Ganem
Kim Wallace Stewart (waitlist only)
Cam Ericksen
Frankie Forrester
Griffin Smith
Kennedy Hanson
Corrine Nightingale
Katya Stark
Any
How did you hear about 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 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
How did you hear about Crybaby?
Any questions or anything else we should know?