Prospective Client Questionnaire
I schedule new clients based on clinical appropriateness and appointment availability.

I'm currently offering Telehealth (video therapy) appointments only. If you prefer in person appointments, please do not fill out this form.

A starting point for all potential clients is to begin by getting some information to ensure that what brings them in falls within my specialization (appropriateness).

Once I receive your answers, I will review them and then be in contact through the contact information you provide.

Talk to You Soon,

Dr. David Rogers, PsyD. LMFT  


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Name and contact information of person to follow up with? *
What is your preferred method of contact?
Clear selection
Telephone Phone Number *
Email Address *
Are you seeking therapy for yourself, others, or both? *
Name and ages of those interested in therapy *
How did you hear about me?
Brief description of the problem(s) you'd like to address, how long it's gone on, and who is involved: *
Is there any physical violence,  or has anyone expressed any statements or engaged in behaviors that suggest they are a danger to themselves or others? *
Required
Are you divorced, separated, or does the problem involve anything custody-related or court-related? (I do not do any family law, don't testify in court, do no forensic work, do no work related to "parental alienation syndrome," and don't do any work with lawyers)? *
Required
Are any substance, alcohol, or process (ex. gambling) addictions/problems present?
Clear selection
Do all those involved perceive that a problem is present? *
Has therapy perviously taken place? If so, when was it and was it successful? *
What would like to be accomplished from therapy (goals)? *
If you have any questions, feel free to include them below.
Prospective Clients Trying to Use Insurance: Please Fill Out the Following Information. Otherwise, please write "private" in the next question.
The following answers are optional.
Who is your insurance provider? If you are not using insurance you can write "private." *
Are you the primary person covered?
Clear selection
If no, what is the name, date of birth, and your relationship to the primary person covered?
What is your Member Number/Subscriber ID?
What is your Group Number (if applicable)?
What is your birthday?
MM
/
DD
/
YYYY
What is your zip code?
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