Please complete the following form as thoroughly as possible. Date Therapy Location (choose one) *In OfficeName & Ages of All Participants Please provide the names and ages for all participantsOccupations Please list occupations of participantsMarital 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/problemsHas there been any Domestic Violence (even if there are no charges)? YesNoWhere/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. Yes, I would like to apply a sliding scaleNo, it is not applicableThe 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 (2 hour) session and you need to arrive 5 minutes before to complete some initial paperwork. Please indicate how flexible you are with your times or if you have special time constraints: Email EmailSubmit