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JOY A. DRYER Ph.D
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Types of Help
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Divorce Mediation
Forms
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Couples Therapy Forms
Divorce Mediation Forms
Resources
Meet Dr. Joy
For Professionals
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I. BASIC INFORMATION
Hidden
Type
Individual
Couples
Mediation
Today's Date
MM slash DD slash YYYY
Name
*
Birthday
*
MM slash DD slash YYYY
Age
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Home Phone
Cell Phone
*
Work Phone
Prefer to be called on which number?
Select
Home
Cell
Work
Email
*
Who (other than children) lives at this address? Give names & relationship. Can a message be left with them? Y / N
Employer
Occupation
Business Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Work Hours
Education (highest level completed)
Are you currently in school?
Yes
No
What are you studying?
Degrees
Source of Referral: Who referred you to me?
II. FAMILY INFORMATION
A. Family:
Mother Alive?
Yes
No
Year Mother Died
Mother's Birth Place
Father Alive?
Yes
No
Year Father Died
Father's Birth Place
Parent's Live together?
Yes
No
Siblings: Names/Ages:
Do any family members have a history of psychological problems?
Yes
No
If so, please describe
Do any family members have a history of medical problems?
Yes
No
If so, please describe
B. Information About CHILDREN
List Name of each Child ,M/F, Date of Birth, Age, Grade Level, Where Resides
(Use new line for each child)
Are there any specific health/educational/mental health requirements for any of these children? For Whom? What?
III. PERSONAL INFORMATION
How long have you been in relationship (in years if applicable)
Partner's Name
If there are unusual circumstances relevant to your relationship, please describe:
Have you been hospitalized for medical reasons?
Yes
No
Describe medical reasons
Have you been hospitalized for psychological reasons?
Yes
No
Describe psychological reasons
Have you ever had any physical or mental illness, significant health problem or serious accidents that affected you for an extended period of time (more than a year)?
Yes
No
If so, please indicate type/ dates/ and current status.
Your health in childhood was generally:
Excellent
Good
Fair
Poor
At present your health is generally:
Excellent
Good
Fair
Poor
When was your last physical?
How often do you exercise?
How often do you meditate?
List medications (including vitamins, aspirin, sleeping pills, etc.) during last 2 years:
If you are currently in any type of therapy or counseling, what kind?
With whom are you in therapy or counseling?
For how long?
Will you give me written permission to speak to your current therapist?
Yes
No
Have you had any history of physical or sexual abuse?
Yes
No
By Whom?
Have you needed to cut back on drinking or drug use?
Yes
No
If so, when?
What substance(s)?
IV. FINANCIAL INFORMATION
Pre-Covid19, what was your approximate Gross income?
Net income?
Current Approximate Gross?
Current Net?
Partner's Net?
Changes in income in the last two years?
Yes
No
And, or expected in next 2 years?
Yes
No
Please explain
Financial concerns you have i should know about?
V. MAJOR LIFE EVENTS or CHANGES
Check all that apply
Started school or training program
Child(ren) born
Fertility problem(s)
Changed job
Lost job
Moved residence
Financial troubles
Increase in financial responsibilities
Legal problems
Separation/divorce of friend/relative
Health problems for yourseld
Health problems for your patner
Health problems for your child(ren)
Death of a close friend.
Death of family member
Death of household pet
Pregnancy, wanted/not wanted
Grandchild born
Miscarriage
Graduated from school/program
Changes in childcare
Trouble with Children?
Onset of menopause
Midlife crisis
Victim of a crime
Undertaken a major new expense
Natural disaster
Child left for college
Child marrying
Anyone added to household
Began treatment for drug/ alcohol problem
Began psychotherapy
Began new medication
Significant weight gain/loss
VI. Emergency Contact:
Emergency Contact Name
Emergency Contact Email
Emergency Contact Cell Phone
Emergency Contact Relationship to you
Insurance Company Name
Who's name is your insurance under?
Yours
Your partners
Isnsurance Phone #
Member #
VII. Your Thoughts:
Please describe briefly why you are seeking professional help? Why now?
What concern(s) do you have for yourself?
For others?
Anything else I should know?
Comments? Questions?