Client Intake Form

Client Intake Form

Please complete this form to help us understand your needs and provide the best care possible.
Client Information

Please provide your personal details.
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Information

In case of emergency, whom should we contact?
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Relationship to You*
Presenting Concerns*
Brief Mental Health History (e.g., previous therapy, diagnoses, medications)
Is there anything else you would like us to know before your first appointment?
Which services are you interested in booking?

Individual TherapyCouples TherapyFamily TherapyYouth Day TreatmentAdult day treatmentCase ManagementSafe and sound protocolOther
Which time of day do you prefer to schedule?

MorningAfternoonLate AfternoonNo preference
Who is your insurance provider?
Member ID
Should be Empty: