New Client Intake Form printable pdf download

CLIENT INTAKE FORM

For therapy services with Jennifer A. Watts, Ph.D., LMFT

Date _______________

25-B Lenox Pointe, N.E., Atlanta, GA 30324

– please print

ENERAL

NFORMATION

Last name _______________________________

First name _______________________ MI ______

Birth date _____/______/_______

Age ________ Sex:  Female

 Male

Referred by (if internet, which site/s?) ____________________________________________________

If a personal/professional referral, may I thank the person? Yes

 No

Street Address _____________________________________________________________________

(street)

(city)

(state & zip)

preferred

ok to leave message?



Cell phone _______________________

Home phone _____________________



Work phone______________________



Email address ______________________________________



Place of Employment____________________________ Length of Employment ___________________

Type of work you do___________________________________________________________________

Highest level of education completed:  High School

 College degree

 Graduate degree

 Professional training  Other _______________________

Relationship status:  single  married/partnered  living together  divorced  widowed

Spouse/partner’s: Name______________________________ Telephone ______________________

Others living in your home (Names/Relationship/Age): ______________________________________

___________________________________________________________________________________

In case of emergency, contact ___________________________________________________________

Relationship ________________________________ Emergency phone _________________________

/ M

OUNSELING

ONCERNS

EDICAL AND

SYCHOLOGICAL

ISTORY

Check any of the following that apply to you and explain

___ Depression_______________________________________________________________________

___ Alcohol__________________________________________________________________________

___ Drug abuse_______________________________________________________________________

Please Note: I do have a 24-hour cancellation policy.

Appointments not cancelled with at least 24 hours notice will be charged at the full rate.

New Client Intake Form

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