{"id":1818,"date":"2021-03-30T22:44:34","date_gmt":"2021-03-30T22:44:34","guid":{"rendered":"https:\/\/ryandykes.com\/?page_id=1818"},"modified":"2021-03-30T22:48:49","modified_gmt":"2021-03-30T22:48:49","slug":"phone-consult-questionnaire","status":"publish","type":"page","link":"https:\/\/ryandykes.com\/index.php\/phone-consult-questionnaire\/","title":{"rendered":"Phone Consult Questionnaire"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1818\" class=\"elementor elementor-1818\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-c30df5d elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"c30df5d\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-d36fd76\" data-id=\"d36fd76\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-05e97e2 elementor-widget elementor-widget-text-editor\" data-id=\"05e97e2\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>This form helps us save time during our consultation by giving me a general sense of what you hope to gain from therapy. You will have the opportunity to discuss these questions more in-depth during our phone call.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-6c93e5d elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"6c93e5d\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-93a580f\" data-id=\"93a580f\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-ffa5440 elementor-widget elementor-widget-shortcode\" data-id=\"ffa5440\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><div class=\"wpforms-container \" id=\"wpforms-1817\"><form id=\"wpforms-form-1817\" class=\"wpforms-validate wpforms-form\" data-formid=\"1817\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/1818\" data-token=\"baabc7843a5197292c6d1a115588a024\" data-token-time=\"1776251506\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-1817-field_1-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"1\"><label class=\"wpforms-field-label\">Initials <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-1817-field_1\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][1][first]\" required><label for=\"wpforms-1817-field_1\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-1817-field_1-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][1][last]\" required><label for=\"wpforms-1817-field_1-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-1817-field_8-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"8\"><label class=\"wpforms-field-label\">Issues that you are struggling with (Check all that apply) <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-1817-field_8\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1817-field_8_1\" name=\"wpforms[fields][8][]\" value=\"Anxiety or social anxiety\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1817-field_8_1\">Anxiety or social anxiety<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1817-field_8_2\" name=\"wpforms[fields][8][]\" value=\"LGBTQIA-related issues\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1817-field_8_2\">LGBTQIA-related issues<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1817-field_8_3\" name=\"wpforms[fields][8][]\" value=\"Low self-esteem or self-worth\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1817-field_8_3\">Low self-esteem or self-worth<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-1817-field_8_7\" name=\"wpforms[fields][8][]\" value=\"Highly-sensitive person\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1817-field_8_7\">Highly-sensitive person<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-1817-field_8_5\" name=\"wpforms[fields][8][]\" value=\"Identity exploration\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1817-field_8_5\">Identity exploration<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-1817-field_8_8\" name=\"wpforms[fields][8][]\" value=\"Body image issues\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1817-field_8_8\">Body image issues<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-1817-field_8_6\" name=\"wpforms[fields][8][]\" value=\"Depression\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1817-field_8_6\">Depression<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-1817-field_8_4\" name=\"wpforms[fields][8][]\" value=\"Past bullying or emotional trauma\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1817-field_8_4\">Past bullying or emotional trauma<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-1817-field_8_9\" name=\"wpforms[fields][8][]\" value=\"Relationship issues\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1817-field_8_9\">Relationship issues<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-1817-field_8_10\" name=\"wpforms[fields][8][]\" value=\"Loneliness\/isolation\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1817-field_8_10\">Loneliness\/isolation<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-1817-field_8_11\" name=\"wpforms[fields][8][]\" value=\"Other\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1817-field_8_11\">Other<\/label><\/li><\/ul><\/div><div id=\"wpforms-1817-field_16-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"16\"><label class=\"wpforms-field-label\">I work exclusively through a secure, convenient telehealth video platform. Are you open to telehealth sessions? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-1817-field_16\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1817-field_16_1\" name=\"wpforms[fields][16]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1817-field_16_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1817-field_16_2\" name=\"wpforms[fields][16]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1817-field_16_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-1817-field_13-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"13\"><label class=\"wpforms-field-label\">I am an out-of-network provider for most insurances. I do not bill insurance directly, but I will work with you to provide receipts and help you determine your out-of-network coverage.  <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-1817-field_13\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1817-field_13_1\" name=\"wpforms[fields][13][]\" value=\"I understand.\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1817-field_13_1\">I understand.<\/label><\/li><\/ul><\/div><div id=\"wpforms-1817-field_15-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"15\"><label class=\"wpforms-field-label\">I work with residents in Illinois and Florida. Which state do you live in? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-1817-field_15\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1817-field_15_1\" name=\"wpforms[fields][15]\" value=\"Illinois\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1817-field_15_1\">Illinois<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1817-field_15_2\" name=\"wpforms[fields][15]\" value=\"Florida\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1817-field_15_2\">Florida<\/label><\/li><\/ul><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"1817\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/ryandykes.com\/index.php\/wp-json\/wp\/v2\/pages\/1818\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-1817\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><\/div><\/form><\/div>  <!-- .wpforms-container -->\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>This form helps us save time during our consultation by giving me a general sense of what you hope to gain from therapy. You will have the opportunity to discuss these questions more in-depth during our phone call.<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"site-sidebar-layout":"default","site-content-layout":"default","ast-global-header-display":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","theme-transparent-header-meta":"default","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","footnotes":""},"class_list":["post-1818","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Phone Consult Questionnaire - Ryan Dykes Therapy<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/ryandykes.com\/index.php\/phone-consult-questionnaire\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Phone Consult Questionnaire - Ryan Dykes Therapy\" \/>\n<meta property=\"og:description\" content=\"This form helps us save time during our consultation by giving me a general sense of what you hope to gain from therapy. 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