Craig Ellis, LPC ~ Client Intake Form

Craig Ellis, MA, LPC Client Intake Form

1512 Fairview Street Houston, TX 77006 713.320.7481
Client Name
Date Of Birth
Address

Street Address

City State

Zip Code
Cell Phone Number
Please enter a valid phone number.
Email
example@example.com
Occupation
Referred By
Primary Reason(s) for Seeking Therapy
Medical Issues
Medications
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.
Guardian Name / Relationship (If Client is a Minor)
Office Policy

Payment is due when services are rendered. A minimum of 24 hours notice is required when canceling or re-scheduling an appointment. Failure to do so may result in you being charged for the missed session. Thank you for your consideration.

Your signature below indicates that you have read and understood the Informed Consent Agreement and Notice of Privacy Practices and agree to their terms.
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Craig Ellis, MA, LPC Client Intake Form