Client Intake Form
New Client Information to request an appointment
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Name of Client (s) and Pronoun *
Parent/ Guardian Information (if applicable)
Email Address: *
Phone Number(s) of Clients *
Do you have a therapist preference? (If you were referred or request a specific therapist please indicate below)
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What prompted you to seek therapy?
Do you feel suicidal, at risk of self harm and or homicidal?  If you answer No, skip the next section. *
If answered yes, do you have an action plan currently in place? (If you answered NO to previous question you can skip this section)
Please indicate how the services will be paid *
Please indicate the INSURANCE CARRIER NAME, D.O.B of the subscriber, ID NUMBER, and GROUP NUMBER  for the plan. If you do not have insurance, please indicate CASH PAY on field below. If you need a scholarship, please indicate the reason why. **Pricing will be discussed on the call with the office manager/therapist once assigned.  *If current insurance ID number is not listed this will delay service. *
Please indicate how soon you would like to begin services. You can request a certain day/time. This is not a guarantee of an appointment. *
We currently offer virtual appointments. If you are looking for in person, please indicate below and the therapist will confirm the choice if available. *
How did you hear about us?  
Any questions about the practice? You will receive a response to the email within 24 -48 hours
Empowered Living                            www.empoweredlivinginc.net
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