Request an Appointment

Easy as 1 - 2 - 3

This intake form is designed to best inform the therapist of your needs. In Section 1, the "Client Information," "Requested Service Information" and "In Case of Emergency" sections are required.  The "Intake/Background" section is recommended and you may fill out as much or as little per your comfort level.

 You will not be able to receive any services until the Section 2 "Agreement" is fully read and signed and you have clicked on the Section 3 "Submit" button.  Please feel free to email us with any questions about this form, at no charge.

Client Information:

Privacy Statement: Any information provided by a consumer or customer via our online forms will be held in the strictest confidence. No information will be shared with others. All submissions will be responded to within two business days.


Last Name: *      First Name: *      Preferred Name:

Email Address: *     
Can we email you regarding this session? yes   no

Skype Username:
While our communications are encrypted and we take all precautions to protect your privacy, please note that we do not control the encryption settings for Skype

Do you agree to use Skype as a mode of communication? Checking 'yes' does not mean that you ever have to participate in Skype sessions, it only gives us permission to communicate with you on Skype if you so choose   yes   no

Birthdate: *      Age:      Gender: Male Female
If you are under 18, a parent / guardian will need to co-sign

Address: *     

City:      State:      Country:     

Are you a California, Connecticut, or Montana resident? yes    no

Home Phone #: *      Cell Phone #:     
Can we leave a message on your phone? yes    no

In Case of Emergency

Who should be contacted in case of an emergency?:
Emergency Contact 1 name:      Relationship to Client:
Cell Phone : Home Phone: Work Phone:

Emergency Contact 2 name:      Relationship to Client:
Cell Phone : Home Phone: Work Phone:


Why are you requesting counseling services at this time? *

Is there anything else about you that you would like me to know?

Agreement:

I have read and complete this form truthfully and accurately as to the best of my knowledge. I have also read and agree to the following:
INFORMED CONSENT
PRIVACY PRACTICE STATEMENT.

I have read and agree with the above agreement

The follwing shall constitute an electronic signature:
Name:
Date:
Name of parent / guardian:
Date:

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