Client Intake Form

Client Intake Form
Full Name*

First NameLast Name
Full Name of partner if couples counseling

First NameLast Name
Gender/Pronouns if you have a preference
Address: You agree to notify me if you are not at this address during our session*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date Main*

DayMonthYear
Birth Date Secondary If Applicable

DayMonthYear
E-mail Main
Partner Email Contact If Applicable
example@example.com
Cell Number Main*
Partner Phone Number if applicable
Emergency Contact Number

Area CodePhone Number
Emergency Contact Name

First NameLast Name
Affirmation of Receipt of, and acceptance of HIPAA, Informed Consent, and Good Faith Estimate forms https://www.alexmackenziemft.com/informedconsent*

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Date

MonthDayYearHourMinutesAM/PM Option
By Submitting this form, you affirm that you have read, understood, and agree to the terms of service document
Should be Empty:

By Submitting this form, you affirm that you have read, understood, and agree to the terms of service document