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.
Sign in to Google to save your progress. Learn more
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? *
Clear form
Never submit passwords through Google Forms.
This form was created inside of Therapy Charlotte. Report Abuse