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If you have questions and would like to contact me to discuss your situation, I have added a questionnaire for you to complete.  All of this is confidential but helpful for me to provide you advice. 

Please take a moment to answer the questions below.  Your answers will give us helpful clues to the healing, self-expression and transformation that you most desire.  It will let us know where you are right now and where you want to go.  If you find it difficult to answer any of the questions, please go to the next.  We'll go over this sheet together.

I look forward to your questions,
Dr. Deborah A. Greco

 

Please take a few moments and complete the following.

Please note, the completion of this form will help me evaluate your situation in greater depth.
All of this information is strictly confidential and will not be discussed with anyone.

 

Enter Today's Date

-- mm/dd/yy

Full Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Home Phone#
Work Phone#
Fax#
Email

Please Select One
Sex ( M/F )        Male Female

Relationship Status     Single Married 
                                      Other: Please Specify  

Children                    Yes  No

 

Is there any area in your life where you are suffering to any degree? Yes  No

If you answered yes, please explain.
                  

 

 

What is your primary concern / desire at this time?   

 

 

 What are you tolerating or "putting up" with in your life?

 

 

        What kind of work do you presently do?
       

 

 

Do you enjoy your work or profession?Yes  No

If you answered no, please explain.

 

 

If you didn't have to work for a living, what would you do?

 

 

What gives you the most pleasure in life?

 

 

What do you most want in life...what would fulfill you?

 

 

Where do you want to be in your life 5 years from now?

 

 

What would be the ideal outcome of our work together?

 

 

What area of life do you desire more of?

If "other" please specify

 

 

How do you rate your stress level on a scale of 1 to 10? ( 10 being the worst )
                                                                                                     

 

 

Please use this area to express any other comments you may have.

 

          Please contact me as soon as possible regarding this matter.

Personal phone consultation time is available on a fee basis.  Dr. Greco accepts the following forms of payment: Checks,Cash, Visa, MasterCard, American Express and Discover.

To schedule a consultation via phone or e-mail, please call (203) 798-8114 during regular office hours of 9:00 a.m. to 2:00 p.m. or send an e-mail to drdebgreco@GrecoMD.com.  Thank you.

Please choose one:

  1 hr $250
  1/2 hr  $130
  15 minutes $75
  Other   How much time?