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.


PERSONAL INFO
Name *
Name
Name of Parent/Guardian (If client is under 18)
Name of Parent/Guardian (If client is under 18)
Address *
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
THERAPEUTIC INFO
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
SELF-DESCRIPTION
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.