Skip to the content
Daniel J. Fox, Ph.D
Home
Books
Videos
Worksheets
Services
Seminars and Presentations
Providers
Menu
Home
Books
Videos
Worksheets
Services
Seminars and Presentations
Providers
Search
Search
Close this search box.
Contact Me
Daniel J. Fox, Ph.D
Contact Me
Search
Search
Close this search box.
Home
Books
Videos
Worksheets
Services
Seminars and Presentations
Providers
Menu
Home
Books
Videos
Worksheets
Services
Seminars and Presentations
Providers
Applied Psychological Services, PLLC Psychotherapy Intake Form
Full Name
Today's Date
Choose your gender
Male
Female
Non-binary
Date of Birth
Home Address
City
State
Zipcode
Email
Is it OK to contact you via email?
Yes
No
OK to leave a message?
Yes
No
Phone Number
Is it OK to contact you at this number?
Yes
No
OK to leave a message?
Yes
No
How did you learn about the psychotherapy services provided at this office:
REASON FOR SEEKING TREATMENT:
What has happened to cause you to seek help now?
What do you hope to be able to do or achieve as a result of treatment?
How do you handle stressors and/or cope with the problems you have described:
Reason for seeking treatment
Consultation only
Consultation and treatment
Submit form
✕