Therapy Inquiry Form for Celebrity & High-Profile Clients

"*" indicates required fields

Name of Contact Person*

Relationship to Client*

Please describe your relationship to the client:*

Contact Phone (U.S.)

Contact Phone (International)

May Dr. Curry call and/or leave a message at this number?*

Please list any restrictions for information communicated via phone and/or voicemail:

Contact Email*

Enter Email Confirm Email

May Dr. Curry email you at this address with information related to her services and/or scheduling an appointment?*

Please list any restrictions for information communicated via email:

Were you referred by someone?*

Yes

Who referred you?*

How did you hear about Dr. Curry?*

What type of service(s) is the client seeking? (Select all that apply.)*

Individual Therapy / Individual Life Coaching

Couples Therapy / Relationship Coaching

Family Therapy / Family Coaching

Please select the client's preferred format for appointments. (Select all that apply.)*

In-Office Visits (Client travels to Dr. Curry's Newport Beach office)

In-Home Visits (Dr. Curry meets with client in their home)

Travel Services (Dr. Curry accompanies client while traveling for on-call services)

Remote/Online Sessions

Anticipated dates of travel:*

OPTIONAL: Client's Name

Please describe the nature of the client's work or public status.*

Client's Age*

For Family & Couples, Enter All Clients' Ages:*

Client #1 Age

Client #2 Age

Current City/Country of Residence:*

Please describe the client's reason for seeking services.*

This field is for validation purposes and should be left unchanged.

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