Individual & Couples Therapy Intake Form
Thank you for your interest. Please complete the form below and we will be in contact with you within 24-48 hours.
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Email *
First Name *
Last Name *
What is the name of person who will be attending therapy with you (if applicable)?
What is their relationship to you?
Phone Number *
How would you prefer to be contacted? *
What is your ethnicity?
What gender do you identify as?
Clear selection
Which pronouns do you prefer to use?
Date of birth
Are you currently employed?
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If yes, where?
Do you have a valid Driver’s License or other State Identification?
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If so, please provide license number and state.
What type of medical insurance do you have?
Why are you seeking therapy?
Have you ever been in therapy before?
Clear selection
Would you described the experience as helpful or unhelpful?
Clear selection
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