Client In-Take Form

Please complete the * sections below to provide the confidential information needed.  The rest of the questionnaire is optional, however, your willingness to complete it will help us know you better as you embark on this journey.

Name *
Name
Address *
Address
Phone *
Phone
Provider Support Phone Number *
Provider Support Phone Number
Would you like to be included on our e-mail newsletter? *
Have you ever seen a mental health professional (Psychiatrist, psychologist, marriage and family therapist, social worker, counselor?)
Do you currently have a therapist you work with?
Are you currently taking any medication for mental health issues?

Thank you so much for providing this information!