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Counseling Intake Form
Counseling Intake
Please complete the following intake information below if you are interested in receiving services from our skilled therapists, and someone will reach out to you to complete the intake process.
Date
*
Date Format: MM slash DD slash YYYY
Client Name
*
First
Last
Address
*
Street Address
Apt.
City
State*
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Please provide the best phone number to reach you at.
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OK to leave messages at this phone number?
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Email
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*
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Date of Birth
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Gender
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Other
Prefer not to say
Parent / Guardian Information (if the patient is a minor)
*
Name
Street Address
Apt
City
State / Province / Region
ZIP / Postal Code
Parent /Guardian Phone if different
Marital Status
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Insurance Infomation
*
Insurance / EAP
Medicaid
None
Availability for Appointment Time*
*
Referral Source
Reason for Seeking Services