DALLAS PSYCHOTHERAPY CENTER

• This form is transmitted to our Dallas/Fort Worth therapists via our secure server, and your information will not be used for any purpose other than this consultation.

• The only required fields are your name and your preferred contact info, although more information will help us match you with the most appropriate therapist

• If you have not received a reply from one of our DFW psychologists within 24 hours, there likely has been a server error. If this happens, please call Dallas Psychotherapy Center at 972-755-0996.

Name:

Age:

Please describe your main reason for contacting us:

Other questions or comments:

To request an initial consultation, please provide your time availability: 

Which location is more convenient for you?

Dallas     Fort Worth

Please check any of the following that apply:

individual therapy  couples counseling

medication evaluation/health package

family therapy  child/adolescent therapy

testing

depression   anxiety   panic attacks   relationship issues   sexual issues

bipolarism   ADHD   career issues   social anxiety   substance issues

sex addiction   weight issues   chronic pain   meditation practice   family issues     

Would you like DPC to call you?

Yes     No

Telephone numbers (one is required if you would like to be called):

Home:        Work:

Would you like DPC to email you?

Yes     No

Email address (we cannot email you without this):