New Client Intake Form (Page 2 of 2) in pdf

New Client Intake Form Page 2

___ Other addictions __________________________________________________________________

___ Serious illness ____________________________________________________________________

___ Violence ________________________________________________________________________

___ Suicide thoughts __________________________________________________________________

Are these currently being treated?

yes ____ no ____

By whom? ______________________________________

Their phone (

) _____________________________ May I contact them? yes ___ no ___

Have you ever been in therapy before? yes ____ no ____

With whom? ____________________________________ When? ___________________________

Their phone (

) _____________________________ May I contact them? yes ___ no ___

How will you know when your therapy is successful?

____________________________________________________________________________________

Realistically, how long do you think this might take? ________________________________________

Payments and Cancellations

I agree to pay for my treatment at the time of service.

I agree that if I cancel an appointment without sufficient notice, I will pay for the time that was saved for

me.

Date ___________________

Signature ________________________________________________________________

Print your name ___________________________________________________________

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 Page 2