DAN CARE CENTER Counseling Intake Form

Client's Name

First NameLast Name

Parents Name (For minors only)

First NameLast Name

Gender of Client

Counseling Request

Client's Date of Birth

Date

Contact Number

Area CodePhone Number

Email Address

example@example.com

Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Marital Status

Occupation

Do you have any of the following conditions? If yes, please select them:

Biological Health Concerns (Click the one you have most often, if none, click other and type n/a)

Cognitive Health Concerns (Click the one you have most often, if none, click other and type n/a)

What is your primary reason for contacting us?

Additional comments

I agree to self pay method of payment with a minimum of 6 session

I CURRENTLY HAVE INSURANCE IF YOU HAVE INSURANCE, PLEASE EMAIL YOUR INSURANCE CARD FRONT AND BACK TO INFO@DANCARECENTER.COM

Please list any medications you are currently taking.

I understand that the information I provide will be treated as confidential in accordance with applicable privacy laws and professional standards. The Center does not sell, resell, or improperly share my personal or protected information.

I certify that the information I provide on this form is true, complete, and accurate to the best of my knowledge. I understand that it is my responsibility to disclose information that may be important to my care. I acknowledge that the Center cannot be held responsible for complications or adverse outcomes resulting from information that I intentionally withhold or fail to disclose.

To the extent permitted by law, I agree to release and hold the Center harmless from claims, expenses, damages, or liabilities arising from inaccurate, incomplete, or withheld information provided by me.

I understand that a $75 no-call/no-show fee will be charged for appointments that are missed without cancellation or communication at least 48 hours in advance.

I understand that after three missed appointments, I may be discharged from services and referred to other appropriate resources when applicable.

By signing below, I acknowledge that I have read, understand, and agree to the statements and policies listed above.

Client Signature

Signature of Parent if under the age of 18.

Date Signed

Date

DAN CARE CENTER Counseling Intake Form

Terms & Conditions