M. Dennis Paul, Ph.D.

Professional Conflict Management Services-------------------- Thought Addiction Specialist

Online Enrollment Form

Question with an * are required. Please be as thorough as possible in answering all questions. When you are done, please hit the SUBMIT button. I will contact you as soon as possible with arrangements for your counseling. If you are presently in CRISIS, please contact your nearest HOTLINE immediately.

*Your Name *Gender
Male
Female
*Date of Birth xx/xx/xxxx Your Street Address Your Town Your State Zip Code *Your Email address *Your Phone # (If electing email or chat you can clear this field with 000-000-0000) Please give area code Occupation *Services you wish provided
Phone Counseling
Email Counseling
Online Chat Counseling
In Person Counseling (Must live within reasonable distance (NH/Ma)
*Please describe the issue(s) you wish to address
*Have you sought help for these issues in the past?
YES
NO
*Are you presently working with another counselor?
YES
NO
Please list any medications you are presently using
Are you:
Married
Single
Separated
Divorced
Unioned
Are You:
Gay
Lesbian
Bi-Sexual
Transgendered
other
Income
7-10,000
10,001-18,000
18,001-24,000
24,001-30,000
30,001-38,000
38,001-45,000
45,001-52,000
52,001-75,000
75,001-100,000
above 100,000
Children?
Yes
No
If Yes, how many, ages, gender
Education
High School/GED
Associate Degree
Bachelor
Master
Doctorate
Additional
Trade School
On the Job Training
*Have you ever been arrested?
Yes
No
*Convicted?
Yes
No
*If yes to the above, please list charges and sentences (if No to the above, please place xxx in the field
Please tell me about yourself (anything you feel will help me assist you in any way)