Divorce Services Intake Form - Cornell & Associates

Name*
First Last
Email*
Interested in virtual or in-person sessions?*
- Online therapy (also known as "Teletherapy")
- In-person (when we are allowed to do so)
- No preference
Are you interested in Discernment Counseling, Divorce Counseling, or Divorce Mediation?*
- Divorce Counseling
- Discernment Counseling
- Divorce Mediation
Have you sought prior counsel? If so, please let us know about the experience, both positive and negative.*
What time would be best in your schedule to meet for therapy?*
Is there a specific therapist you would prefer to work with?*
- NO PREFERENCE
- ANTONIA DI LEO
- KEITH DIXON
- SHIRA ETZION
- MELISSA FULGIERI
- ELISA GIZZO
- BREANA JOHNSON
- TRACY CAVELL KEATS
- KARA MCELANEY
How did you hear about us?*
Is there anything else you would like us to know about you? Any other questions for us?*

Divorce Services – Intake Form