New Clients

New Client Intake Form

The New Client Intake Form helps us get to know you, your current circumstances, and what you’re hoping to gain from our work together. Your responses help us tailor our approach to best support your goals and ensure our sessions are as effective and meaningful as possible.

Your Name

First Name

Last Name

Your Partner's Name

Your partner's first name

Your partner's last name

Please upload a photo of the couple together.

Choose File

About You

Gender identity

Another identity

Date of Birth

Age

Your Email

Mobile Phone

Home Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Education and Occupation.

Education Level

Currently enrolled in:

Occupation

Employer/Company

Work Phone

About Your Relationship

Marital Status

Length of your relationship.

About Your Children (if any)

Number of children.

Ages of your children in birth order.

Gender of your children in birth order.

Miscellaneous Information.

Current or history of substance abuse or prescription medications.

What is the reason that you are seeking therapy?

What would you like to accomplish through therapy?

Emergency contact.

Name

Phone/Mobile