Intake Form

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This intake form is required before we can begin any therapy. To save yourself, and us, some time, take a moment to fill out all of the information below. You will need your insurance information to complete this form.

We ask that you thoroughly read through all parts of this form, paying close attention to the Counseling Agreement at the very bottom which lists what we will expect from you and what you should expect from us.

We are excited to work with you and hope that you find our help life-changing!


Client Information
If you have a spouse, child, and/or significant other, please fill out the second section below "Additional Clients"
Name *
Name
Phone *
Phone
Contact *
When and how should we contact you? Please check all that apply.
Address *
Address
Date of Birth *
Date of Birth
What is your race and/or ethnic origin.
What do you currently do for a living? If you have more than one job, please list them. Who is your employer?
As a small business, referrals are invaluable to us. We would love to personally thank whoever referred you to us. If it was an online or advertising source, we want to know what's working and what's not. Please feel free to leave any feedback here about your experience in finding out about us.
Additional Client Information
Please fill out if applicable.
Name
Name
Phone
Phone
Emergency Contact Information
Primary Care Doctor *
Primary Care Doctor
Doctor's Phone Number *
Doctor's Phone Number
Nearest Relative or Friend *
Nearest Relative or Friend
Relative or Friend's Phone Number *
Relative or Friend's Phone Number
Medication
Include name, dosage, and length of time you have been taking each medication.
Insurance Information
You can typically find this information on the back of your insurance card.
Ex: Aetna, BlueCross
Phone Number *
Phone Number
Address *
Address
Name of Account Holder *
Name of Account Holder
This is typically the person who receives the insurance through their employer.
Account Holder's Date of Birth *
Account Holder's Date of Birth
Insurance Release
Authorization to Release Information and Assignment of Insurance Benefits *
Counseling Services Agreement
Please Check each box below. You will be held to the terms of the agreement below.
Counseling Agreement *
The relationship between a therapist and a client requires a sense of mutual trust and understanding. As we begin our work together, we wish to explain at the outset what you should expect from us and we will expect from you. If you have any questions, please stop and call or e-mail us first, we want you to fully understand and agree to each item below, freely and without pressure or confusion. We sincerely look forward to working with you.