Client Intake Form
This form usually takes 5-10 minutes to complete. Completing this form is optional, and the choice to complete or not to complete this form will not affect your ability to be involved in therapy with Dr. Briggs.
Todays Date:
MM
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DD
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YYYY
Personal Title:
First Name:
Your answer
Middle Name:
Your answer
Last Name:
Your answer
Street Address:
Your answer
City:
Your answer
State:
Your answer
Zip Code:
Your answer
Email Address:
Your answer
Primary Phone Number:
Your answer
Secondary Phone Number:
Your answer
Birthdate:
MM
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DD
/
YYYY
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