Intake Form

Please take some time by yourself to answer these questions to the best of your knowledge, as of today.
This form is meant to be a comprehensive understanding of your current life experience and background.

Name *
Name of Parent/Guardian (If client is under 18)
Name of Parent/Guardian (If client is under 18)
Address *
Cell Number *
Cell Number
Note: Texting is not considered a confidential method of communication
House Number
House Number
Date of Birth *
Date of Birth
Marital Status *
Partner's Name
Partner's Name
Check any that apply to you. *
In childhood AND as an adult
Better yet, do you have any free time?
What is the last grade of school that you completed? Scholastic abilities: strengths and weaknesses? Were there any problems with truancy, suspensions, special education, vocational training, etc.?
Have you seen a Psychotherapist previously? Medications? If so, please list name and dosage
Complete the following statements. Don't think to much, just type the first thing that comes to mind.
How did you find me?

I appreciate you taking the time to fill this out.