Intake Form | Tony Fryer Marriage and Family Therapist

Please complete the following form as thoroughly as possible.

Date

Name & Ages of All Participants

Please provide the names and ages for all participants

Occupations

Please list occupations of participants

Marital Status and Any Previous Marriages/Partnerships (of All Adult Participants)

Children and Ages

Please provide the names of all children and their ages (if any)

Brief Description of Issues/Problems

Please provide a brief summary of any issues/problems

Has there been any Domestic Violence (even if there are no charges)?

Where/Who were you referred to me from?

Please indicate if any of the participants has been diagnosed with a mental health issue(s) and what the diagnosis was

My fee is $240/hr. I DO NOT USE INSURANCE. I do provide a sliding scale for gross household incomes under $220,000 and where there are no other significant assets.

Yes, I would like to apply a sliding scale
No, it is not applicable

The sliding scale is available for financial hardship. Please ask about it if you feel it is applicable.

If you answered "Yes" to the sliding scale, please provide your financial details (including income) here:

Your first visit is a double (1 hour 45 min) session. Please indicate how flexible you are with your times or if you have special time constraints.

Please give email addresses of all participants. *

Participant One

Additional Email Address

Participant Two

Phone