Therapy Intake Form Patient's Name * First Name Last Name Child's Date of Birth (or your own if seeking treatment services for yourself) * MM DD YYYY Preferred Phone Number Country (###) ### #### Is it okay to leave a voicemail? Yes No Preferred Email Address Is it okay to E-mail? Yes No Is this referral for yourself or your child? If for yourself, skip to question 10. Myself My Child If the referral is for your child, please list all guardians and in the case of separation/divorce, indicate who has medical decision making authority: In the case of separation/divorce, are parents struggling to co-parent effectively or is there conflict in the parenting relationship? Please briefly describe the main concerns you are seeking help for at this time. Is there any other information that you think would be relevant for us to know at this point? Is there a specific psychologist(s) that you wish to work with? In matching you with a psychologist, do you have any preferences you would like us to consider? What type of service are you looking for? * In person Virtual Either/both How did you hear about our clinic? Are there any specific services you are looking for (e.g., groups, workshops, intensives, etc.)? Thank you! Our office manager will be in touch within the next week to take you through the next steps.
