Intake Form

Intake Form

Redefining You Therapy, Inc respects your right to privacy. This "Authorization for Use or Disclosure of Protected Health Information Form" provided by Redefining You Therapy Incorporated follows HIPPA guidelines.
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Today's Date*
Your Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Your Age*
Phone Number
Please enter a valid phone number.
Your Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name & Relationship of a close relative/friend in the event of an emergency:
Emergency Contact
Emergency Contact Phone
Please enter a valid phone number.
Current Problem(s)
What do you want to address in Therapy?:*
What happened that made you decide to come in at this time?*
What would you like to change about yourself to make your situation better?*
Should be Empty:

Current Problem(s)