Intake Form – Patient Financial Form

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- Our Story
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Intake Form – Patient Financial Form

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Name *

First

Last

Best Number To Reach You *

Email *

What type of counseling do you need? *

Counseling for my child
Couples counseling
Family Counseling
Counseling for myself

If you are not certain, please list what you feel would be the most important primary service to start with. The intake coordinator will support you during the scheduling process.

Please specify the clients age range. *

Under 6
7 to 12
13 to 17
18 to 25
26 to 39
40 to 60
61 +

Please check multiple age boxes if needed.

Please share what brings you to therapy. *

Please only add information you are comfortable sharing. This is not a HIPAA compliant form. The completion of the form does not establish a counselor and client relationship.

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