Greg Dunford Counseling Services
Intake Form
Practice Policies
Informed Consent

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Welcome to Greg Dunford Counseling! We look forward to working with you.
PLEASE CAREFULLY READ AND FILL OUT ALL SECTIONS. ONCE SUBMITTED, YOU WILL NEED TO NOTIFY US OF ANY CHANGES YOU WISH TO MAKE.
How did you hear about me?
Client Information
Full Name *
Date *
MM
/
DD
/
YYYY
Preferred Name
Phone number *
Email *
Best way to reach you *
Required
Gender
Clear selection
Birthdate *
MM
/
DD
/
YYYY
Street Address 1 *
Street Address 2
City *
State *
Zip *
Marital Status *
Services Requested
If you checked Marriage/Partnership Counseling, add name of spouse/partner(s).
Relationship
Full Name
Cell Phone
Email
Do we have permission to contact this individual with information about ways we can support them and their loved ones?
Clear selection
What are you hoping to achieve in therapy?
List Medical Conditions
Medications
Mother/Guardian Information
If client is under 18 years of age
Relationship
Full Name
Cell Phone
Email
Address
Enter only if different than client
Street Address 1
Street Address 2
City
State
Zip
Do we have permission to contact this individual with information about ways we can support them and their loved ones?
Clear selection
Father/Guardian Information
If client is under 18 years of age
Relationship
Full Name
Cell Phone
Email
Address
Enter only if different than client
Street Address 1
Street Address 2
City
State
Zip
Do we have permission to contact this individual with information about ways we can support them and their loved ones?
Clear selection
Payment Information
Type of Payment *
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