Intake Form

The following client intake form is confidential and will only be shared with your therapist and is used for administrative purposes.

Following this, please fill out our Cancellation Policy Agreement.

Name

First Name

Last Name

What's the name of your insurance carrier?

What is your insurance ID number?

What is your insurance group number?

Home Address

Please include your full address (state and zip code)

Phone Number

(###)

###

####

Date of Birth

YYYY