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.
Email address *
Todays Date:
MM
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DD
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YYYY
Personal Title:
First Name:
Middle Name:
Last Name:
Street Address:
City:
State:
Zip Code:
Primary Phone Number:
Secondary Phone Number:
Birthdate:
MM
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DD
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YYYY
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