Intake Form

Please complete as much of this form as is comfortable before your first psychotherapy or psychological testing session. (This information will be reviewed with you and is only meant to facilitate the intake process).

Patient name




Phone/email





Is it OK to leave messages on cell phone?

Is it OK to Text to cell phone?

Is it OK to email?

Address




How do you describe your race/ethnicity and gender?


Current marital status (Check one)
Highest degree obtained (Check only one)
What best describes your current employment status?
What is your occupation?
Please briefly state the primary reason for your visit today
Insurance Information

Are we filing?