(Docked Ships) Profile Information for Free 15-Min Consultation

Welcome to Docked Ships

We're more than just a company; we're a movement at Docked Ships, LLC! We're dedicated to revolutionizing the social health and wellness of African American women, smashing those unrealistic expectations of being superhuman. Ready to join us? It’s easy to get started—just sign up for a free 15-minute consultation by providing a few quick details. A friendly representative from Docked Ships, LLC will reach out within 24-48 hours after you submit your information. Let’s make a change together!
Name? *

First NameMiddle NameLast Name
Email address?*
example@example.com
Physical mailing address? Please do not list a PO Box. *

Street Address

Street Address Line 2

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Zip CodeCountry
Is it ok to leave a confidential message at the email listed above?*

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What is a cell phone number, in which we can text?*
Please enter a valid phone number.
Is it ok to leave a confidential text message and/or voicemails at the cell phone number listed above?*

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Please indicate the best date and time to contact you for a brief consultation.*
Please indicate the next best date and time to contact you for a brief consultation.*
Services of Interest (Tier 1)

Docked Ships, LLC addresses social health and wellness issues faced at every level - (Tier 1) from communities and organizations to (Tier 2) to individuals to groups. PLEASE BE SURE TO SCROLL DOWN TO TIER 2 SERVICES OF INTEREST, IF ONLY INDIVIDUAL OR GROUP SERVICES ARE BEING REQUESTED.
Please identify Tier 1 service(s) of interest.

Educational ServicesOrganizational Consulting
Name of Company or Organization?
Relationship to Company or Organization?
Please briefly explain the context of your current concerns.
Services of Interest (Tier 2)

Social health and wellness issues addressed at the individual and group level (Tier 2).
Please identify Tier 2 service(s) of interest.

Individual Coaching ServicesIndividual Therapy ServicesGroup Coaching ServicesFamily Therapy ServicesCouples Therapy Services
Today's Date

MonthDayYear
Date
Client's Age
What is your date of birth?

MonthDayYear
Date
What is your administrative gender?

FemaleMale
What is your identified ethnicity?

Hispanic/LatinoAmerican Indian/Alaska NativeAsianBlack/African AmericanNative Hawaiian/Other Pacific IslanderWhite/CaucasianIdentified ethnicity not listed
Referral Source (Tier 2)
How did you hear about us?

Psychology TodayTherapy for Black GirlsHeadwaySimple PracticeGoogleInstagramFacebookTwitterYoutubeYour Insurance ProviderA Friend, Family Member, and/or AcquaintanceA Former ClientA Wellness Professional
If you indicated a person as your referral source, please let us know the name of the individual.

First NameLast Name
If you are interested in therapy, will you use your insurance benefits? NOTE: Insurance can ONLY be utilized for the identified therapeutic/counseling services.

Yes, Oscar Health.Yes, Blue Cross, Blue Shield.Yes, Aetna.Yes, Oxford.Yes, Cigna.Yes, United HealthNo, I will be paying for services out of pocket.
Noted Concerns of Referral (Tier 2)
Please briefly explain the context of your current concerns.
Should be Empty:

Welcome to Docked Ships

Services of Interest (Tier 1)

Services of Interest (Tier 2)

Referral Source (Tier 2)

Noted Concerns of Referral (Tier 2)