A confidential, evidence-based assessment to help Dr. Nicole & Roy serve you with wisdom, care, and intentionality.
Basic details about you and your partner
Understanding where you are and where you're headed together
Assessing your friendship, communication, and shared foundation
Identifying what is working well in your relationship
Understanding the families that shaped you — and what you're bringing into your marriage
Every couple has areas of friction — understanding yours helps us help you
Your safety and wellbeing are our first priority
What would make this journey a success for you?
A brief, validated screening for anxiety and depression (last 2 weeks)
Over the last two weeks, how often have you been bothered by the following?
PHQ-4 © Kroenke K, Spitzer RL, Williams JB, Löwe B. Psychosomatics. 2009;50(6):613-21. Used for clinical screening purposes.
A validated 9-item clinical screening tool (last 2 weeks)
Over the last two weeks, how often have you been bothered by any of the following?
PHQ-9 © 1999 Pfizer Inc. All rights reserved. Reproduced for clinical intake purposes. PRIME-MD is a trademark of Pfizer Inc.
Rate your current level of peace or satisfaction in each life area (0–100%)
For each area below, enter a number from 0 (no peace/satisfaction) to 100 (complete peace/satisfaction). Be honest — there are no right or wrong answers.
Identifying pain points that may affect your relationship and wellbeing
List up to 5 pain points — things that cause you significant emotional pain. Give each one a title that truly captures your feelings. Use the category codes below:
For communicating with Dr. Nicole E. Francis Cotton & Roy Cotton Jr.
About communicating via email with Dr. N. Erna Mae Francis Cotton and Roy Cotton Jr.:
Please read the following disclosures about communicating with Dr. N. Erna Mae Francis Cotton and Roy Cotton Jr. using e-mail.
E-mail is not secure or confidential. Hackers and unauthorised users can also attempt to access email through malicious software such as spyware or viruses that may block or cause damage on your computer. However, there is no guarantee that such programmes will always be effective.
Sent and received e-mails are stored on Dr. Erna Mae Francis Cotton's and Roy Cotton Jr.'s computers until deleted. Many people still feel comfortable communicating via e-mail because they have installed firewalls or other programmes designed to detect spyware, viruses, or other dangerous software.
Any saved e-mails will be kept in a password-protected account that only Dr. Erna Mae Francis Cotton and Roy Cotton Jr. have access to. In addition, whenever you send an e-mail, it is stored in cyberspace and the authorities can access these e-mails under various circumstances — this is due to the nature in which e-mail is transmitted using the internet and other service networks.
For more information on this, please contact your Internet Service Provider or e-mail service.
Dr. N. Erna Mae Francis Cotton and Roy Cotton Jr. will use e-mail to respond to e-mails that you send them. If you request that your billing statement be e-mailed to you, they will do so. A rule: Dr. Erna Mae Francis Cotton and Roy Cotton Jr. do not conduct any therapy via e-mail. However, they may use e-mail to handle certain questions or issues that pertain to therapy and related content, if they can be easily and simply handled by that means.
At their discretion, they may also choose to refrain from using e-mail communication for therapeutic reasons.
By submitting this form, your typed name above serves as your electronic signature confirming you have read and understood the above disclosure. A witness signature will be requested at your first session if required.
Your responses will be sent securely to Dr. Nicole Francis Cotton & Roy Cotton Jr. You will receive a confirmation and they will be in touch within 48 hours to schedule your first session.
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