Name
*
First Name
Last Name
Email
*
Company Name
Phone
*
Country
(###)
###
####
City, State where you live?
*
Country?
*
How can I add value to you?
*
Individual counseling
Couples counseling
Family counseling
Group counseling
LMFT-Supervision
Leadership/Business consulting
Mental/Peak Performance coaching
Other
What did you have in mind as far as your time in therapy?
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I desire to give you the service you WANT vs. the service that I think you NEED.
Feel free to elaborate more if you selected "other"
What are the top concerns in your life that you desire to focus on and/or change?
*
For those seeking therapy or coaching.
What do you currently believe you have control over in your life?
*
For those seeking therapy or coaching.
Change is sometimes easy, sometimes hard, or somewhere in between. It all depends. On a scale of 0 to 10, how willing and ready are you to do the work that is necessary to grow and change?
*
0= I'm not ready at all (Either because of fear, not feeling comfortable changing, etc...)
10= I'm extremely motivated and ready to do whatever it takes. I need change/growth NOW!
What is your creative spark?
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(i.e. paint, draw, dance, sing, write books/poetry/songs, I build ___ (DIY style), I make ___ (i.e. scarfs, music beats), play an instrument, entrepreneur, etc...)
Anything else you'd like to share about your needs?
How did you hear about Dr. Small?
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Shrink Space Directory
Therapy Tribe Directory
Psychology Today Directory
Therapy for Black Men Directory
Therapy for Black Girls Directory
BEAM- Black Virtual Wellness Directory
Word of Mouth/ Someone Referred Me
Dear Future Wifey Podcast
Newspaper/Magazine
Dr. Small TEDx talk
Google Search
Social Media
Radio/TV
Other