Jeanne Courtney, MFT

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Request an Appointment with Jeanne Courtney

By answering these questions, you can help me get to know you, and get a head start on providing the best therapy for your needs. Please fill in as much or as little information as you feel comfortable with. The only required fields are your first name and phone number. After you submit the form, I will call you within two business days, to answer any questions you have and confirm an appointment. If you would like to reach me sooner, or prefer not to use the form, you can simply call me at 510-527-5662 ext 2.

(Use cursor or TAB key to move to the next field; hitting ENTER will submit the form.)

First Name:
Last Name:
Age:
Phone(s):
Address:
City:
Zip Code:
Email:
Type email again:
Okay to leave a message?

How did you hear about me?
Please specify:
What brings you to therapy?
Type of therapy you want::
For family / couples therapy, enter names of everyone coming in and have each adult submit this form separately.

Frequency you want:

Please check all possible appt times:
		Tues afternoon, El Cerrito
		Tues evening, El Cerrito
		Wed afternoon, San Francisco
		Wed evening, San Francisco
		Thur morning, El Cerrito
		Thur afternoon, El Cerrito
		Thur evening, El Cerrito
Comments about scheduling:
How will you pay?
If Medi-Cal, do you also have Medi-Care?
If paying independently, do you need to request a low-income fee reduction?
If yes, indicate gross (before taxes) annual household income from all sources:

No. of adults in household:
No. of children:
Please list any psychiatric medications you take:
Have you ever . . . had drug or alcohol problems?
. . . thought about or attempted suicide?
. . . been stalked, threatened, or assaulted?
. . . experienced domestic violence?
. . . done anything violent?
Please describe:
How long since you had a therapist?
Comments about past therapy:
What is stressful in your life right now?
What is going well in your life right now?
Anything else you want me to know?