New Client Intake Form

Please complete this form before your first appointment. All information is kept strictly confidential.

Personal Information

First Name *

Last Name *

Date of Birth *

Preferred Pronouns

Contact Information

Street Address *

City *

State *

ZIP *

Phone Number *

Email Address *

Preferred Contact Method

PhoneEmailText

Emergency Contact

Name *

Relationship *

Phone *

Referral Information

How did you hear about us?

Presenting Concerns

What brings you to therapy? *

Areas of concern (check all that apply)

AnxietyDepressionTrauma/PTSDRelationshipsGrief/LossStressSelf-EsteemSubstance UseOther

Treatment History

Have you been in therapy before?

YesNo

If yes, please describe your previous therapy experience

Current Medications (if any)

Goals for Therapy

What do you hope to achieve through therapy?

* Required fields