Client Intake Form
New Client Information to request an appointment
Email address *
Name of Client (s) *
Phone Number(s) of Clients *
Do you have a therapist preference? (If you were referred or request a specific therapist please indicate below)
How did you hear about us?
What prompted you to seek therapy
Are you feeling suicidal? *
If yes, do you have an action plan currently in place? (If you answered NO to previous question you can skip this section)
Do you have an active insurance plan? Please indicate the INSURANCE CARRIER NAME,D.O.B, ID NUMBER, and GROUP NUMBER for the plan. If you do not have insurance, please indicate CASH PAY on field below. **Pricing will be discussed on the call with the office manager once intake is received. *
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.
Any questions about the practice? You will receive a response to the email within 24 hours
Empowered Living Inc www.empoweredlivinginc.net
OFFICE USE ONLY: Therapist Assigned to Client:
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