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Intake Form for Amelia Canally Therapy
Hi and welcome to my practice! Here is the New Client Paperwork for starting individual, couple or group therapy with me. If you are initiating couple therapy, please have each person complete the form for themselves. Please reach out via email or text if you have any questions. Thanks and see you soon!   -Amelia
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First and Last Name: *
Phone Number: *
Email Address: *
Full Home Address (including City/State/Zip): *
Date of Birth: *
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Age: *
Who lives in your household: *
Who would you like as an emergency contact. And what is their relationship to you? *
Emergency contact email and phone: *
What is your educational background? *
What is your profession/job? *
Are you taking any medication? Who prescribes it? *
Do you have any concerns about your use of drugs or alcohol? *
Who referred you to me? And may I thank them? *
Tell me about your previous experience with therapy: *
Why are you seeking therapy now? *
What else would you like me to know about you? *
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