Journey Ahead New Client Intake

Form 1 of 4 Intake Form

Intake Consent HIPAA Insurance

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

Phone Email Text

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)

Anxiety Depression Trauma/PTSD Relationships Grief/Loss Stress Self-Esteem Substance Use Other

Treatment History

Have you been in therapy before?

Yes No

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

Your progress is automatically saved as you fill out the form.