THERAPIST SUPPORT FORM

Full name

Email

Phone

Preferred Contact Method

How did you hear about DLR Counseling Group?

What is your current professional role?

Are you currently receiving clinical supervision?

Yes

No

Are you seeking therapy for yourself, not supervision or consultation?

Yes

No

I'm not sure

What brings you to therapy at this time?

How long have these concerns been affecting you?

Have you been in therapy before?

Yes

No

If yes: What was helpful? What wasn’t?

Do you understand that I cannot be both your therapist and your supervisor?

Yes, I understand

No, I need clarification

What do you hope to gain from therapy with me?

Preferred Format

Telehealth (Texas only)

In‑person (Colleyville)

Preferred Frequency

Weekly

Biweekly

Monthly

Not sure

Payment Method

Private pay

HSA/FSA

Out‑of‑network benefits

Not sure

Are you currently experiencing thoughts of harming yourself or others?

Yes

No

If yes, Please describe what’s going on so I can direct you to the appropriate level of care.

Anything else you want me to know before we schedule?

Would you like to receive updates, resources, or program announcements from DLR Counseling Group?

Yes, I want to choose what I receive

No, I do not want to receive emails

If yes, which of the following would you like to receive?

Grief & Loss Workshops

Men’s Emotional Health / Brotherhood 2.0

Couples & Relationship Work

Mental Health Education & Tools

Free Resources (guides, videos, downloads)

Upcoming Events & Live Experiences

DLR Counseling Group Updates

I understand this form is for therapy only, not supervision or professional services

YOU SPEND YOUR DAYS HOLDING SPACE FOR OTHERS. THIS IS YOUR SPACE

THERAPIST SUPPORT FORM