Request for Therapy Form

Hello there! Thank you for taking the time to tell me more about yourself and your therapy needs. I'm so glad that you reached out.

Please note that this form is confidential and private and will delivered to me through an encrypted email platform. Filling out this form is the first step to see if your therapeutic needs meet with my experience and expertise.

Please note that the completion of this form neither means I am your therapist nor means that I have availability in my schedule to receive new clients. The goal of this form is to help us determine if my expertise and your therapy needs match. The client/therapist relationship is important, and I want to make sure I'm the right fit for you.

With your best interests at heart, I do not accept health insurance, and am considered a "private pay therapist." If your insurance plan allows, you may be able to use my services as an out of network provider.

If you wish to use your health insurance, and you are looking for referrals, I would recommend using the find-a-therapist search engine located on Psychology Today.

Whew ... now that we got all the legal stuff out of the way ... let's get to the good stuff! :)

Your Contact Information

Today's Date

Your name

Your email address

Your phone number

Generally speaking, what type of work do you do?

Health Insurance Usage

Even though I do not take insurance, I am required to ask the following questions. Please check the most appropriate box:

I am on Medicare

I do not have medical insurance.

I have medical insurance, but I want to keep my information PRIVATE and CONFIDENTIAL without even letting my insurance company know I'm in therapy. I will NOT submit Out of Network claims to my insurance company, and will use the services of Tim McDaniel as a private pay practitioner.

I pride myself in keeping people's information private and confidential. That's how we build trust with one another! What is discussed in therapy is between you and I -- not between you and I and your insurance company. We can discuss privacy in more detail when we talk on the phone.

I have medical insurance, and will use Tim McDaniel's services as an Out of Network Provider

There are LIMITS to confidentiality and other concerns using your Out of Network benefits: I must diagnosis you with a mental health disorder and your insurance company has a right to see your file. I am happy to discuss this LACK of privacy and confidentiality when we talk on the phone. To learn more about using your out of network benefits, and the complications that may occur, please visit https://www.therapywithtim.com/fees-and-payment-options

I want to use my insurance benefits.

Keeping your confidentiality and privacy at heart, I am neither credentialed on any insurance panels nor do not take insurance.

Referral Resource

Who referred you to my therapy practice, or how did you hear about me?

Would you give me permission to reach out to this person to thank them for the referral? No identifying information about you will be shared--just a "thank you for the recent referral you sent my way."

Yes, you are welcome to contact them.

No, please do not reach out to them.

Therapist Preferences

What are you looking for in a therapist?

Past Therapy Experience

Please check the appropriate boxes that apply to your past therapy:

I have been in therapy before, and it was helpful.

I have been in therapy before, and it wasn't helpful.

I have never been in therapy.

Did your therapist give you a mental health diagnosis? If yes, please list below. If no, please list NA.

I have seen more than one therapist in my lifetime:

Yes

If yes, please say more about that. If no, please list NA.

Past Psychiatry Experience

Please check the appropriate boxes that apply to your past psychiatry:

I am currently seeing a psychiatrist.

I have never seen a psychiatrist.

I have seen a psychiatrist in the past.

Did your psychiatrist give you a mental health diagnosis? If no, please list NA.

Are you currently on any mental health medications? If no, please list NA.

I have seen more than one psychiatrist in my lifetime:

Yes

If yes, please say more about that. If no, please list NA.

Suicide and Thoughts of Death and Dying

Please check all of the appropriate boxes that describe suicidal behavior:

I have neither had suicidal thoughts nor had any plans or intent on killing/harming myself.

I have had thoughts of death and dying, but they didn't include plans or thoughts of killing/harming myself.

I have had passive suicidal thoughts in the past, but they were just thoughts. There were no plans or intent on killing/harming myself.

I have been actively suicidal in the past with a plan and with intent on killing/harming myself.

I have had a suicide attempt(s) in the past.

I am currently having suicidal thoughts.

If you are currently suicidal, have a specific plan to kill yourself, and have the intent on doing so, please call the Suicide Hotline at 1-800-273-8255 or chat with a professional by visiting https://suicidepreventionlifeline.org/chat, or call 911.

Support Systems and Close Relationships

Therapy Needs

Tell me a little bit about what you'd like to talk about in therapy.

Getting In Touch

When would be a good time to contact you via telephone to discuss this information further? I will do my best to accommodate your schedule.

May I email you to either set up a phone call or to communicate other information? Email communication provides limited privacy, please limit personal identifying information in your emails. I will do the same.

Yes, you can email me.

No, please do not email me.

Thank you for taking the time to fill out this secure form. Once you click on the "submit" button, it will be delivered to my encrypted email inbox. Upon receiving this information, I will contact you so we can discuss this information further.

Thanks, and I look forward to talking with you soon. --Tim

Your information will be encrypted.