New Therapy Client Intake Form

First name

Last name

Email

Phone

Client's Date of Birth

Month

Day

Year

How would you prefer to be contacted?

Phone

Email

Text

Any of the above

I prefer to meet

In person

Online

I'm flexible

Qualities I look for in a therapist include...

A sense of humor

Someone who listens without interrupting

Someone who challenges me

Someone who is good at problem-solving

Someone who provides structure

Someone who gives good feedback

Someone involved in the LGBTQ+ community

Someone who has a positive outlook

Someone who is nurturing

If you were referred by your PCP, what is their name?

Name of Insurance (if none, please write N/A)

Member ID (if none, please write N/A):

Group RX Number (if none, please write N/A):

Days/times you are available:

Multi-line address

Country/Region

Address

City

Zip / Postal code

Are you a veteran or an active member of the military?:

Do you have a history within the last 6 months of suicide attempt?:

Are you currently involved in any legal disputes?:

Are you currently in a household that is experiencing domestic violence?:

*Domestic Violence is a condition that requires special care and expertise. Please let our Intake Specialist know if your are currently in a situation where you are experiening DV or if you are at risk of DV so they can do their best to help you find the right services.

If you are seeking services for your child, please describe the marital and custody status of the child's parents. Is DCF involved?:

Tell us a little about you, and your situation to help us match you with the right person:

Keep me in the Loop! I'd like to learn more about upcoming events and services!

Office Hours 10am-4pm M-Th
Therapy Hours: 7am-8pm M-F & Weekends By Appointment

Welcome! We're so happy you found us :) If you're ready to take that first step, just fill out this form and we'll get started...

New Client Intake

Welcome! We're so happy you found us :) If you're ready to take that first step, just fill out this form and we'll get started... New Client Intake

Welcome! We're so happy you found us :) If you're ready to take that first step, just fill out this form and we'll get started...

New Client Intake