(Docked Ships, LLC) Profile Information for Free 15-Min Consultation

Referral Profile Information

Information needed for free 15 minute consultation. A Docked Ships, LLC representative will contact you within 24-48 hours of completing this form.
Today's Date

MonthDayYear
Date
What is your name? *

First NameMiddle NameLast Name
What is your email address?*
example@example.com
Is it ok to leave a confidential message at the email listed above?*

YesNo
What is your physical mailing address? Please do not list a PO Box. *

Street Address

Street Address Line 2

CityState

Zip CodeCountry
What is a cell phone number, in which we can text?*
Please enter a valid phone number.
Is it ok to leave a confidential text message and/or voicemails at the cell phone number listed above?*

YesNo
Referral Demographic Information
What is your date of birth? *

MonthDayYear
Date
Client's Age
What is your administrative gender?

FemaleMale
What is your gender identity?

WomanManTransgender Woman / Trans FeminineTransgender Man / Trans MasculineNon-Binary / Genderqueer / Gender FluidOther
What are your affirming pronouns?

She/Her/HersHe/Him/HisThey/Them/TheirsOther
What is your identified ethnicity?

Hispanic/LatinoAmerican Indian/Alaska NativeAsianBlack/African AmericanNative Hawaiian/Other Pacific IslanderWhite/CaucasianIdentified ethnicity not listed
Referral Source
How did you hear about us?

Psychology TodayTherapy for Black GirlsHeadwaySimple PracticeGoogleInstagramFacebookTwitterYoutubeYour Insurance ProviderA Friend, Family Member, and/or AcquaintanceA Former ClientA Wellness Professional
If you indicated a person as your referral source, please let us know the name of the individual.

First NameLast Name
Services of Interest
Please identify services of interest.

Entrepreneurial CoachingOrganizational Employee CoachingCouples Relationship CoachingRelationship Growth (Individual) CoachingCouple's Relationship Dynamics Assessment (Prepare & Enrich)Reiki TrainingCouples & Family Reiki TrainingSelf-Knowledge (Identity) CoachingTrue Colors Personality Assessment & ReportTrue Colors Personality Assessment Results ConsultationTeam Building (Group Dynamics) Training & ActivitiesParenting TrainingIndividual CounselingCouples CounselingFamily CounselingSelf-Care Well Care ActivitiesSelf-Care Well Care Tools & ResourcesKeynote SpeakerWellness Workshop Facilitator
If you are interested in individual, couples, and/or family counseling, will you use your insurance benefits? NOTE: Insurance can ONLY be utilized for the identified therapeutic/counseling services.

Yes, Oscar Health.Yes, Blue Cross, Blue Shield.Yes, Aetna.Yes, Oxford.Yes, Cigna.Yes, United HealthNo, I will be paying for services out of pocket.No, I am not interested in counseling services.Other
Noted Concerns of Referral
Please briefly explain the context of your current issues.
Please indicate the best date and time to contact you for a brief consultation.*
Please indicate the next best date and time to contact you for a brief consultation.*
Should be Empty:

Referral Profile Information

Referral Demographic Information

Referral Source

Services of Interest

Noted Concerns of Referral