• Client Intake Form

    Please complete this intake form to help us understand your background, current concerns, and treatment needs.
  • Client Information

    Please provide your personal and contact details.
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  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Mental Health & Medical History

    Tell us about your mental health and medical background.
  • Current Symptoms

    Check any symptoms you are currently experiencing.
  • Treatment Goals

    Help us understand your goals for therapy.
  • Risk Assessment

    Your safety and well-being are our priority.
  • Consent & Acknowledgment

    Please review and acknowledge the following.
  • 1. Unless there is an emergency, all the therapy sessions are private and confidential with the exception of specific exceptions described below: a. Child, elder or dependant abuse, b. Expressed threats of violence toward an ascertainable victim, c. Detailed planning or concrete signs of future suicide attempts, d. Sharing information is necessary to facilitate client care across multiple providers, e. Sharing information is necessary for the treatment, f. Requests from legal and administrative institutions. 2. With the Client's prior written consent, the Counselor may legally speak to another healthcare provider or Client's family members in emergency situations. The Client may direct the Counselor to share information with whomever the Client desires, and the Client may change his/her mind anytime and revoke the permission. 3. The Counselor is allowed to keep brief notes compiled by AI of the therapy session which shall be kept in strict confidence. 4. The Client may ask questions on what to expect during and end result of the therapy. 5. The Client may decline to proceed the therapy as to the techniques which may be conducted by the therapist. 6. The Client may cease to continue therapy anytime, without any impediment and may return to therapy anytime. 7. The therapist has the right to dismiss the Client from the course of therapy.

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  • Should be Empty: