Therapy & Life Coaching with Teresa Thomas, LMFT
Thank you for choosing Resilience & Love Academy. This intake form helps me understand what you are currently experiencing, what brought you to therapy/life coaching. Once you submit the form I will reach out to you to schedule your first session.
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Marital Status
Please Select
Single
Married
Divorced
Widowed
Email
*
example@example.com
Employment
Please Select
Employed
Unemployed
Disabled
Retired
Student
Phone
*
Format: (000) 000-0000.
Preferred Method of Contact
E-mail
Phone
Insurance Information
for Texas Residents only
Insurance Company Name
Subscriber Name
First Name
Last Name
Subscriber Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Subscriber Relationship to Patient
Group Number
Policy Number
What are you needing right now?
What service are you seeking at Resilient Love Academy: Burnout Recovery, Life Coaching, 7am Reset Session, Individual Therapy, or Couples Counseling?
*
What is your primary concern in your life and/or relationship right now?
*
Have you seen a life coach, counselor, psychologist, psychiatrist or other mental health professional before?
Yes
No
Additional comments or concerns or questions
*Your signature below indicates that the information you have provided above is truthful.
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
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