Client Intake Form

Please complete this form before your first session. All information is kept strictly confidential and protected under HIPAA guidelines.

Personal Info

Reason & History

Insurance & Billing

Consent & Submit

Personal Information

Please provide your current contact details and demographic information.

First Name *

First name is required.

Last Name *

Last name is required.

Date of Birth *

Please enter your date of birth.

Gender Identity

Email Address *

Please enter a valid email address.

Phone Number *

Please enter a valid phone number.

Current Address

Reason for Visit & History

Help us understand your needs so we can match you with the right therapist.

Primary Reason for Seeking Therapy *

Please select a primary reason.

Please describe your symptoms or challenges *

Please provide a brief description.

Have you had therapy before?

Current Medications

If yes, please list them

Emergency Contact *

Emergency contact is required.

Insurance & Billing

We accept most major insurance plans and offer sliding-scale options.

Payment Method *

Please select a payment method.

Insurance Provider

Policy / Group Number

Subscriber Name (if different)

Upload Insurance Card (Optional)

Accepted: JPG, PNG, PDF (Max 5MB). Securely encrypted.

Consent & Agreement

Please review and accept the following policies to complete your intake.

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Confidentiality & HIPAA Notice: All information you provide is protected by federal and state privacy laws. Your data will only be used for treatment purposes and shared only with your explicit written consent, except in cases of imminent danger or mandatory reporting laws.

I have read and agree to the Privacy Policy & HIPAA Notice.

I understand the Cancellation & Payment Policy (24-hour notice required to avoid fees).

I confirm that the information provided is accurate and complete to the best of my knowledge.

I consent to receiving appointment reminders and clinical communication via email or text.

Please agree to all consent statements to proceed.

Digital Signature *

Digital signature is required.

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Intake Submitted Successfully

Thank you for taking this important step. Our clinical team will review your information and contact you within 24 hours to schedule your first session.

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