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New Client Forms | Creative Expressions Consulting, LLC
Please take 10-15 minutes to read through and fill out the following forms 24 hours prior to your first Art Therapy session with Lynn Cukaj.
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Client's Full Name
*
Your answer
Today's Date
*
MM
/
DD
/
YYYY
Parent/Guardian name if client is a minor
Your answer
Home Address
Your answer
Email Address
*
Your answer
Main Phone Number
*
Your answer
Can we leave a voicemail?
Yes
No
Clear selection
Can we text you?
Yes
No
Clear selection
How did you hear about Lynn Cukaj?
Your answer
What are the current issues and concerns?
Your answer
Medical information (diagnosis, allergies, medications, special needs/limitations, developmental level)
Your answer
When did you first learn about diagnosis/condition/psychological concerns?
Your answer
Family history & sibling information:
Your answer
Psycho/social history:
Your answer
Any previous treatment/therapy to address these concerns?
Your answer
What are your short-term goals?
Your answer
What are your long-term goals?
Your answer
What are your/your child's strengths and interests?
Your answer
Do you have art materials or creative preferences?
Your answer
Additional information that would be helpful:
Your answer
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