CLIENT INTAKE INFORMATION & AGREEMENT
Name: __________________________________________ Date: _________________
Age: _____________ Date of Birth: __________________________________________
Marital Status: ____________________ (single, partnered, married, separated, divorced, widowed)
Names & Ages of Children (if applicable): _____________________________________
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Home Address: ___________________________________________________________
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Email Address (optional): __________________________________________________
Phone Number(s): ________________________________May we leave a message Yes___________No_____________
Occupation: _____________________________________________________________
Emergency Contact Person’s Name and Phone Number: __________________________
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Referred by: (name & phone number): ________________________________________
Reason for seeking therapy at this time: _______________________________________
Have you previous received any type of mental health services? No Yes Previous Practitioner_________
Please list current prescription medication___________________________________________________
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General and Mental Health Information
Poor Unsatisfactory Satisfactory Good Very Good
Poor Unsatisfactory Satisfactory Good Very Good
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Length of time_______________________________________________________
Approximately when did you begin experiencing this? __________________________
If yes, please describe____________________________________________________
Daily? Weekly? Monthly? Infrequently? Never?
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Additional Information
Current employment_______________________________________________
Do you enjoy your work?
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
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I understand that all fees are due at the time of service, and that at least 24 hours’ notice is required for cancellation of appointments. Should I cancel my appointment less than 24 hours in advance, I understand that I will be responsible for paying the full fee charged for my session. By signing below I agree to all of the above.
Signature of client: _________________________________ Date: _________________