NEW CLIENT
CHILD/MINOR INTAKE FORM

Contact Information

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 sheet to make sure I have all information required for my records. We will also explain our policies regarding confidentiality and fees associated with your therapy. Please 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? (selec all that apply)

Therapist Preference

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

CATEGORY 1 - Licensed

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CATEGORY 2 - Registered

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CATEGORY 3 - Trainee/Intern

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