Client Intake/Consent Form
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
Type of Service
What brings you in today?
Please Select
Licensed Clinician (Therapy)
Licensed Clinician (Coaching)
Support Groups
sliding scale therapy
***sliding scale therapy is only available in Florida 1:1 therapy is available in FL, SC, and MN
Authorization
By submitting and signing this form, I acknowledge, and consent to the following:
By submitting this form, I confirm that the information provided is accurate to the best of my knowledge. I consent to Quiet Contemplation using this information solely for the purpose of responding to my inquiry, scheduling services, and providing relevant follow-up communication. My information will not be shared outside of Quiet Contemplation without my permission.
Date
-
Month
-
Day
Year
Date
Signature
Submit this form to schedule a free 15 minute consultation call.
Print Form
Continue
Continue
Should be Empty: