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?
*
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
*
Is it ok to leave a voicemail at this phone number?
*
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.
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?
*
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:
*
When meeting with my therapist, I prefer:
*
How did you hear about Crybaby?
Any questions or anything else we should know?
