New Client Form

Before completing the form below, please read and review the following:

Please complete the form below and submit prior to your first session.

Name

First Name

Last Name

Email

Date of Birth

MM

DD

YYYY

Phone (home)

(###)

###

####

Phone (mobile)

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Permission

May I send appointment confirmations, invoices, or other counseling-related information to your email?

Phone Permissions

May I leave voice messages or send texts regarding appointments, invoices, or other counseling-related information?

Emergency Contact

Please provide the name. phone number, and relationship of person to contact in case of emergency:

Referral Source

How did you hear about my counseling services?

Consent Form Review

By entering my name below, I confirm I have read and understand the Counseling Informed Consent Form and agree to the terms regarding the Providing of Counseling Services.

First Name

Last Name

Financial Responsibility

By entering my name below, I confirm understanding of the requirement for payment at the time of each session and that I will be charged for sessions cancelled less then 24 hours before my scheduled appointment.

First Name

Last Name

HIPAA Acknowledgement

By entering my name below I acknowledge the receipt and review of the HIPAA Privacy Policy.

First Name

Last Name