Client Intake Form

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Client Intake Form

Thank you for your interest in pursuing services with Kathryn Zawislak Therapy & Associates. Please take a moment to fill out our intake form, answering questions as completely as possible.

If you are filling out this form for multiple people, please complete separate forms.

Email *

Client Full Name

Clients Date of Birth *

YYYY

Email address *

Phone Number
*

Please tell us why you are seeking treatment? *

Select the types of services you're interested in *

Individual Therapy

Family Therapy

Couples Therapy (Private pay or must have one primary client only when billing insurance)

Required

List any history of psychiatric diagnosis and/or care: *

Is there any court/legal involvement? *

Yes

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