Stephen Britchkow, Psychologist

New Clients: Pre-Session Information Form - Book An Appointment

Welcome

Thank-you for choosing to contact me for services.

I am currently scheduling new client appointments for couples, families, individual adults and children. Services are provided in your home or office (provided you're in my service area) or at my Lower Bucks County, PA location.

It's easy to request an appointment using the request form. Here's how:

    Check the checkbox beneath as many times as will work for you. Since some times will already be scheduled, choose at least five possible times.

  1. If you do not see a time on the form that meets your needs, please indicate what time(s) you need in the "Comments" box.

  2. Complete the form and press the Request Appointment button

  3. I will attempt to contact you by phone and/or e-mail no later than the next business day to confirm your appointment.

* Items starred in RED are required

Possible Appointment Times*
Day Times
Monday 10:00
11:00
12:00
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
Tuesday 10:00
11:00
12:00
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
Wednesday 10:00
11:00
12:00
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
Thursday 10:00
11:00
12:00
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
Friday 10:00
11:00
12:00
1:00
2:00
3:00
 -   -   -   -   - 
Saturday - No Appointments Scheduled -
Sunday - Special Appointments Only -


My first name:*
My last name:*
My e-mail address is:*
Type e-mail address again to verify:*
Best telephone number to reach me:* (Area code first)
Other number (optional): (Area code first)
Zip Code:*  

Your age:*

How much education have you completed?*

What is your current employment situation?*

How many people do you live with?*

What are their ages and relationship to you?


If you are contacting me for couples counseling, please enter your spouse or partner's name:

Describe the situation you would like to address in counseling.*
(All information submitted is securely encrypted for your privacy.)


Please describe any physical symptoms you may be experiencing:


Are you taking any medications at present? If so, list:


How long have you been dealing with the issues which are causing you to seek help?*

Use the space below for additional comments or concerns.

    Please let me know:

      The best time(s) and days for me to reach you by phone

      Any special instructions re: leaving voicemail or messages when I call

If you are filling out this form to request services for someone other than
yourself and/or your partner, please explain below.