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.

Note: Payment is expected for any missed session, unless the appointment is cancelled at least 36 hours in advance. 

Directions: Kayla is located on the 3rd floor of the 1954 Angus St building. You can park on either side of Angus (in front of the building - parking is free for 2 hours). Enter the building from the front - come up to the stairs to the third floor. The door signage says Red Fox Creative Studio.

About the STUDIO: FYI - Kristin (Kayla's business partner) may be working in the studio. The space you will walk into is a large studio (EAST STUDIO), Kayla's office is in the middle of  the studio.
 You can have a seat on the teal couch in the WEST STUDIO and Kayla will come and get you.