KHTG Intake Form

Intake Form

Kindred Heart Therapy Group
Welcome to Kindred Heart Therapy Group's intake form. Please fill out all sections of this form & submit it back to our team. After we receive your form our team will review it and a clinician will reach out to schedule.

Thank you, Kindred Heart Therapy Group, A Non-Profit Corporation!
Client's name:*

First NameLast Name
Client Date of Birth:*

MonthDayYear
Date
Client Personal Pronoun (e.g.: she/her, he/him, they/them):
Client Gender:
Client phone number:*
Please enter a valid phone number.
Client email address:
example@example.com
What type of services are you seeking? (You can only select one option)*

Individual TherapyFamily TherapyCouples TherapyOther
If you are seeking additional services from our office please use this link. A new tab will open with the form you need to complete to request those services.
Please write the first & last names of all parties you wish to include in your session.
If you are seeking Family or Couples session please include email address for all adults involved:
Are you or any other party currently a client with Kindred Heart Therapy Group?

YesNo
Client address: (If you are using your insurance make sure this matches the address you have on file with your insurance company.)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Method of Communication

Phone callEmailText Messaging
If the client/child is under the age of 12 years old please answer the following:
Parent/Guardian Name

First NameLast Name
Parent/Guardian Phone Number:
Please enter a valid phone number.
Parent/Guardian Email Address:
example@example.com

Intake Form

Kindred Heart Therapy Group
Can you briefly share what you are wanting to work on in therapy?:*
Do you have any legal issues / issues with law enforcement and / or prior felonies?*
Should be Empty: