Client Intake Form

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Have you ever experienced any of the following?

Occupational Information

Educational Information

Religious / Spiritual Information

Marital Information

Family Composition

Other Information

Consent For Communication
No Show, Late Cancellation and Co-payment Policy
Health Insurance Claim Form
Credit/Debit Card Agreement

Primary Insurance Information:

Initial here

Self Pay Agreement:

Please Initial

SECONDARY Insurance Plan (If not applicable, skip)

Patient’s or Authorized Person’s Signature: I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment claims related to medial services provided.


Please Initial