Request A Therapy Test Drive Appointment

Emergency Assistance

If this is an emergency, DO NOT complete this form. Please go to the nearest hospital and ask to speak to the duty psychiatrist or Call:

911 (USA) / 988 (USA)
999 (UK)

Welcome to CBT Gym! I want to make sure that I will be a good (hopefully great) fit for you. Could you please help me begin to learn more about you and what you are looking for?

Full Name

What would you like me to call you?

Date of Birth? (please write out day, month, year)

Phone number

Email address

Are you seeking therapy for yourself? Please note that it is my policy to only communicate directly with potential clients. If you are wanting to help a loved one, please ask and / or help them to complete this form directly.

Yes

How are you wanting to meet? Studies show that working online is as effective as in person therapy. That being said everyone is different which is why I am asking for your preferences below!

Online In person Either is fine!

Are you currently seeing a CBT Therapist, Mental Health Counselor, Psychotherapist, Psychologist or Social Worker?

Yes No

Would you be open to participating in online group therapy?

Yes

How may I contact you? (Note: Email is required. More = Better!)

Text Message

Voicemail

Phone

How did you hear about CBT Gym?

Were you referred to me? If so, who referred you?

What about CBT Gym interests you most?

Have you had Therapy, CBT, Counseling or Coaching in the past? If so, what was helpful? What was unhelpful?

What do you hope to get out of Therapy / CBT / Counseling / Coaching?

How do you plan to pay for sessions?

Self Funding / Out of Pocket Private Insurance

If I do not take your insurance as an in network provider, do you have out of network benefits AND would you be interested in being seen on an out of network basis?

Yes No

Fees for US clients are $185 (for USA) / £150 (for UK) per session. to be paid in advance for any scheduled sessions in a calendar month. Can you please confirm your agreement to this in principle?

Yes No

Is your Bupa policy for Bupa UK or Bupa Global?

What is your pre-authorization number?

How many sessions have been approved (If you have used any of your sessions, how many are left)

Please let me know all of your evening availability to meet (which days and times)?

Please let me know all of the days and times you can meet (please include your time zone).

Would you likely be able to attend an appointment with little notice ? If I receive a late cancellation, I may be able to offer you an appointment, but without much notice.

Yes, please try me No, I definitely need notice

It if meant a shorter waiting time for you, would you like me to try to provide a referral to another therapist?

How much do you believe therapy will help (on a scale of 1 to 10, where 1 is not at all and 10 is definitely) Please give any comments that would be helpful for me to know.

Do you have any questions or comments for me? Anything else you want me to know?

Thank you for taking the time to help me learn about you. I'll be in touch!

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