Therapy Charlotte LLC
In preparation for your first appointment, please complete the following form. The information you provide here is protected by law and held in strict confidence.
Full Name: *
Home Address
Birth Date *
Current Occupation: *
Primary Phone Number *
May I leave a message? *
E-mail Address *
May I e-mail you? (Please note: E-mail correspondence is not considered to be a confidential medium of communication) *
Name of emergency contact: *
Phone number of emergency contact: *
How did you hear about Therapy Charlotte? *
Areas of Concern: Please check all that help describe your concerns or goals. *
In your own words, what do you hope to get out of the therapy or coaching experience? *
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