‘From Under the Rug’ Mental Health Therapy Intake Form
This form will ask you general questions and provide your therapist with a brief overview.
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First Name Last Name *
Date of Birth *
Residential Address *
Email Address *
Phone Number *
What is your preferred contact method? (Text is easiest and fastest way to communicate. E-mails will definitely come in the form of PayPal messages for invoicing, calendar invites for sessions, and notifications about changes with the practice.) *
Emergency Contact Name *
Emergency Contact’s Phone Number *
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