Intake Form

Please note that this form should be completed by the person(s) who will be participating in therapy services. Exceptions are made if the intended client (1) is a minor (under 18) and you have legal guardianship or (2) is an adult and you have legal adult guardianship.

New Intake Form

  • (i.e.: Self, adopted child, foster parent, significant other, spouse, etc.):
  • :
  • Friend, Colleague, Doctor, Therapist, Teacher, etc.

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