Contact Information

NEW CLIENT
ADULT INTAKE FORM

Thank you for considering us for your counseling needs.

 

To request an appointment we'll need some information from you to get started. Please complete our new client form to save time during our first session. 

At the beginning of our first session, our therapist will briefly review the information provided to make sure we have all information required. We will also explain our policies regarding confidentiality and fees associated with your therapy. During your appointment, please feel free to ask us any questions you have about therapy; as we are here to serve you and to make you comfortable during this process. If you would like a copy of our HIPAA Privacy Practices you can review them here.

Sex
May the therapist leave a voice or text message?
If necessary may we send mail to your address?
Marital Status

Appointment Time Preferences

Which days of the week do you prefer? ( (select all that apply)
Time of day you prefer? (select all that apply)

Therapist Preference

PLEASE SELECT TWO (2) THERAPIST OPTIONS FROM ONE (1) CATEGORY BELOW

CATEGORY 1 - Licensed

CATEGORY 2 - Registered

CATEGORY 3 - Trainee/Intern

arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v