Client Forms Please fill out prior to your appointment, or arrive 10 minutes early to fill out in person. Thank you! Online Client Intake Form: If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required First Name * Last Name * Address 1 * City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code * Phone * Email * Age * Sex * Date of Birth * Marital Status Occupation Employer Current Household Members (Name, Age, Relationship to Client) Current Household Members (Name, Age, Relationship to Client) Current Household Members (Name, Age, Relationship to Client) Current Household Members (Name, Age, Relationship to Client) Previous Psychiatric Hospitalizations and/or Outpatient Counseling Dates & Where Current Medications and Physical/Medical Conditions at this time: * Briefly state the reason you are seeking counseling at this time. * Primary Insurance Company ID# Group # Insurance Phone # Name of Insured, if different than client Employer of Insured Insured's Date of Birth Relationship to Insured: Secondary Insurance Company Secondary Insurance Number Name of EAP company (if applicable) EAP Phone Number EAP Authorization Number Number of Sessions Authorized Prove That You're Human: What is 2 + 2 ? *
