Counseling Cove PLLC Client Information Intake Form
Please fill out this intake/information form before your first session. During your first session, I will go through a thorough intake interview. Thank You!
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Last Name, First Name
Date of Birth *
MM
/
DD
/
YYYY
Preferred E-Mail *
Sessions are conducted through Google Meet, so make sure you use an e-mail you will be able to access- as you will need to access the same e-mail each time, and documents, questionnaires etc are also sent through google sheets, docs, etc. A gmail works best, but if you do not have one you can use a different one.
Address *
City *
State *
Zip *
Primary Phone Number *
Check all that apply:
Emergency Contact First and Last Name *
Relationship to you *
Emergency Contact Phone Number *
I am seeking help for (check all that apply) *
Required
Do you want to use insurance or will you be doing private pay? *
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