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Directions for Forms:

1) Please complete the following sections of the New Client Intake by typing your responses in the box under each heading. Once complete, click submit.

2) Carefully read the Therapy Agreement and Consent Form. Sign and click submit.

New Client Intake (Secure and Confidential Submission)


Today's Date

Client Name

Client Date of Birth

Client Age


Client Sex

Parent/Guardian Name (If Minor)

Contact Numbers

Email Address

Physical Address (include city and state)

Client Insurance, Member ID, Group #, Effective Date, Address/contact #

Primary Care Office

Employer or School Name/Grade

Any School or workplace related difficulties

Reasons you are seeking counseling

Initial Goals

Appointment/Provider Preferences/Accommodations

History of Medical Conditions

Developmental Delays/Conditions

Social or Communication Concerns

History of Mental Health Conditions and Treatments

History of Substance-use Conditions and Treatments

Trauma History

Inpatient Admissions (Dates/Facilities please)

Legal Issues or Court Involvement (includes custody)

Family Wellness Center Disclosure and Consent Form

Please review, sign and submit.

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