Intake Questionnaire
Welcome, new Clients! Thank you for your interest in TL Solutions. Please complete this form in its entirety to get started.
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1. Name *
First and Last Name
2. Date of Birth *
3. Email *
4. Phone number? When is the best time to contact you? *
5. Race/Nationality *
6. Address *
7. Do you have insurance? If so who is your insurance provider? What is your insurance number?    (Information is utilized to verify coverage and determine Copay responsibility) *
8. What is your current issue? How long has this issue been going on? *
9. Do you currently have any legal issues? Are you or your child involved in litigation? *
10. Have you filed a restraining order against anyone? Has anyone filed a restraining order against you? Is anyone harassing or stalking  you? *
11. Why do you want to work with me? How did you hear about my practice? *
12. Have you ever had Therapy before? If yes, when? With who? Why did you stop? *
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