Please fill out this form prior to your appointment. Url Dr. Feldman is offering therapy by phone or video call while we are asked to stay at home. Name * Address (include city, zip) * Your Age * Email * Phone Number * Employment/ position or indicate if stay at home parent How did you learn about my practice? * Briefly describe your reasons for seeking therapy * Are you currently taking any medications for psychological purposes? Please indicate. Have you engaged in psychotherapy or couples therapy before? If so when? Briefly describe your experience. Emergency Contact Info: Name of Emergency * Phone Number * Relationship to Emergency Contact