Individual Wait List Intake Form – Nick Doolittle, LiCSW

Full name *

What do you prefer to be called? *

Email *

Phone number

Brief description of what brings you to therapy. No need to go into a lot of detail, I just want to make sure I'm the right fit for your particular issues and circumstances. *

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

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 3:00pm (my last session of the day is 2:00pm), Monday through Friday. Occasionally, I'm able to offer virtual-only 4pm or 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.