Therapist

Select a therapist and proceed with your registration.

Chidi Ndubueze, MHR, LPC, LADC/MH

Name

First Name

Last Name

Date of Birth

Gender

Female

Male

Race/Ethnicity

Click all that apply

White

Asian

American Indian

Black/African-American

Pacific Islander

Hispanic

Not Hispanic

Mixed

Marital Status

Please select

Email Address

Phone Number

Your therapist will contact you on this number to confirm your appointment.

Address/City/State/Zip

Emergency Contact Name & Phone #

Insurance

Please Refer to the CONTACT page for a list of Insurance that Chidi accepts

Insurance Member ID Number

Military Affiliation (Past or Current)

Current Symptoms or Concerns

Childhood Experiences or Issues

Short Description of Trauma if applicable

For married and engaged couples only. Do you get physical with each other when you escalate?

Yes

We used to but not anymore

History of Prior Treatment/Counseling

Family History of Mental Health

Education

Occupation

Hobbies & Social Activities

Community integration/involvement

History of Medical Health

Alcohol/Drug Use (Include Frequency & Age of First Use)

Tobacco user?

Yes

Current Medication List (Include Uses and start Dates)

Allergies

What is your religious preference?

Select problem areas if applicable

Job-related problems

social or Legal Problems

Interpersonal problems

Difficulty carrying out identified roles

Academic problems

Difficulty with self-care/basic needs

What Are Your Strengths? What Motivates You?

List below, other goals not mentioned above, that you would like to accomplish in therapy

Add a Date & Time for Your First Appointment

Chidi will contact you to confirm this date & time

Name

First Name

Last Name

Date of Birth

Sex

Phone

(###)

###

####

Email Address

What Do You Need the Assessment For?

License is revoked or suspended due to DUI/DWI or Other Drug/Alcohol-related.

License is active and this assessment is court-ordered or suggested by your attorney but has no relevance to your driver's license status

Date

Add a Date for your assessment. Chidi will contact you within 24 hours to confirm this date.

YYYY

Office Visit or Virtual Visit

Indicate below if you would prefer a virtual assessment to office visit.

Office visit

Virtual Visit/Telehealth

Message

Therapist(required)

Select a therapist and proceed with your registration.

Chidi Ndubueze, MHR, LPC, LADC/MH

Name(required)

First Name

Last Name

Date of Birth(required)

Gender(required)

Gender

Female

Male

Marital Status

Please select

Email Address(required)

Phone Number(required)

Your therapist will contact you on this number to confirm your appointment.

Address/City/State/Zip(required)

Emergency Contact Name & Phone #

Insurance (required)

Please Refer to the CONTACT page for a list of Insurance that Chidi accepts

Insurance Member ID Number(required)

Military Affiliation (Past or Current)

Current Symptoms or Concerns(required)

Childhood Experiences or Issues(required)

Short Description of Trauma if applicable

For married and engaged couples only. Do you get physical with each other when you escalate?

Yes

We used to but not anymore

History of Prior Treatment/Counseling(required)

Family History of Mental Health(required)

Education(required)

Occupation(required)

Hobbies & Social Activities(required)

Community integration/involvement

History of Medical Health(required)

Alcohol/Drug Use (Include Frequency & Age of First Use)(required)

Tobacco user?(required)

Yes

Current Medication List (Include Uses and start Dates)(required)

Allergies(required)

What is your religious preference?

Select problem areas if applicable

Job-related problems

social or Legal Problems

Interpersonal problems

Difficulty carrying out identified roles

Academic problems

Difficulty with self-care/basic needs

What Are Your Strengths? What Motivates You?(required)

List below, other goals not mentioned above, that you would like to accomplish in therapy

Add a Date & Time for Your First Appointment

Chidi will contact you to confirm this date & time

Name(required)

First Name

Last Name

Date of Birth(required)

Sex

Phone

Email Address(required)

What Do You Need the Assessment For?

License is revoked or suspended due to DUI/DWI or Other Drug/Alcohol-related.

License is active and this assessment is court-ordered or suggested by your attorney but has no relevance to your driver's license status

Date(required)

Add a Date for your assessment. Chidi will contact you within 24 hours to confirm this date.

Office Visit or Virtual Visit

Indicate below if you would prefer a virtual assessment to office visit.

Office visit

Virtual Visit/Telehealth

Message

Online Registration