New Client Requesting Appointment
First Name
:
Last Name
:
Street Address
:
City
:
State
:
Zip Code
:
Phone/ Home
:
Cell Phone
:
First & Last Name of Emergency Contact:
Phone Number of Emergency Contact:
Your Email Address:
Presenting
Problem:
Your Diagnosis if any
:
Current Medications:
Previous Counseling When?
Where?
:
When is the Best Time for Your Session?
1. Pre-pay for Session 2. Complete Intake Form 3. Matched to a Therapist
