New Client Consultation Form
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
What city and state do you reside in?
*
Street Address
Street Address
City
State / Province
Postal / Zip Code
Back
Next
Do you prefer follow-up contact about this form to be by email or phone?
*
Phone
E-mail
What time of day is best to contact you?
*
Please Select
9:00am-12:00pm
12:00pm-3:00pm
3:00pm-6:00pm
Briefly share why you are seeking therapy:
*
0/050
Have you ever participated in therapy?
*
Yes
No
Please list any previously diagnosed mental health disorders.
*
0/50
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Next
Do you have any current legal issues?
*
Yes
No
If you answered yes to the previous question, what type(s) of legal issues do you currently have? (please check all that apply):
*
Criminal/Civil.
Child Protective Services
Family Court
Other
Do you have active insurance?
*
Do you have active medical insurance?
*
Yes
No
Please provide the name of the medical insurance company you are covered under and whether it is private, medicaidy, Medicare.
*
Submit
Should be Empty: