EasyToTalkTo.com  Prospective Client Information

Enter the information asked for by typing within each box. Boxes expand to fit what you write, but if there is not enough room for your response, just continue within another box. It is okay if what is already written by us within a box is deleted by your response.

Your responses are sent to our confidential and secure email account

at state-of-the-art secure Swiss email service ProtonMail.

Any and all information you enter at this website is not kept at our website and so your submission is secure.

Your responses are sent to our confidential and secure email account

at state-of-the-art secure Swiss email service ProtonMail.

Any and all information you enter at this website is not kept at our website and so your submission is secure.

Which therapist would you prefer to meet with? Type "Susan Griffith" or "Richard Cooper" or "either".

At which office would you prefer to meet? Type Durham (Durham/Chapel Hill office) OR Graham (Alamance County/Graham office)?

When are you able to come to our office for therapy visits (days with time ranges?)

What is the most perfect time of day (for instance, 4:30 pm, 12 noon, etc.) for you to start your sessions with us? Is that for all days, or just one day?

What are the first name or nickname and last name that we should call you?

How old are you?

Type your email address.

Type your phone number. Write TEXT after the number if you don't mind receiving texts from your therapist.

Give us family, social, work or educational information you care to share.

Share any family (or other) names, ages, and descriptions that you wish to share.

What would you like to ask us?

How do you want your visits with us to be different from any prior counseling?

What goals do you have for your work with us?     Please note: We no longer provide work release assessments and work disability reports for new and not-current clients.

Tell us about current and past health concerns.

What else do you want to tell us now? (About anything).

Health/Medical Insurance Company Name or Names on your insurance card.

Health/Medical Insurance: Type your Insurance Policy Number as it is written on your insurance card.

Type your Name as your Health /Medical Insurance Company has it on the insurance card.

Type your Address as your Health/Medical Insurance Company has it on the policy.

Type your date of birth as your Health/Medical Insurance Company has it on the policy.