Couples Wait List Intake Form – Nick Doolittle, LiCSW

Your full name *

What do you prefer to be called? *

Your email address *

Your phone number

Your partner's full name *

What does your partner prefer to be called? *

Your partner's email address *

Your partner's phone number

Do you prefer email, calls, or texts for communication? *

Email
Phone calls
Phone texts

Are you looking to meet in-person, virtually (through telehealth), or some combination? *

In-person
Virtually (telehealth)
Both

How are you looking to cover the cost of therapy? *

Private pay
DHMC insurance
Out-of-network insurance

Information on billing and insurance be found here.

Brief summary of what leads you to couples therapy. No need to go into a lot of detail, I just want to make sure I'm the right fit for what you are needing.

I tend to meet weekly with new clients by default, unless a client has a preference otherwise. At what pace would you like to begin therapy, schedules allowing?

Weekly
Every other week
Other (explain below)

Scheduling preferences and limitations. I'm usually in the office 8:30am to 3pm (my last session of the day is 2pm), Monday through Friday. Occasionally, I'm able to offer virtual-only 5pm times to those who need to meet later in the day. If there are particular days/times that work (or don't work), let me know. Knowing this in advance can help me carve out the right times to fit your schedule as you rise to the top of the list. I can't always control where/when I will have availability, but I'd like to try and accommodate your schedule where I can.