Client Intake Form:



Today’s Date:_______________

Client Information:

Full Name:_______________________________ Date of Birth:_________________

Address:________________________________________________________________

Home Phone:_____________________

Best way to reach you (cell phone, email, home phone):________________________

Email:__________________________________

Emergency Contact:_____________________________________________________

Who to thank for referral:_______________________________________________

If you can, please state what you hope to achieve through therapy:








_______________________________________________________________________________________________________________________________________________________________________
Payment Information:

Responsible Party’s Full Name:___________________________________________

Address (If different from above)______________________________________________

_______________________________________________________________________

Insurance Carrier:__________________________________________________________

Name of Insured and birthdate________________________________________________

ID Number:_________________________________________

Group Number:______________________________________

Signature of responsible party:__________________________________________