
Therapy Intake Form
I look forward to working with you.
Please provide the following information for my records. Leave blank any question you would rather not answer. Information you provide here is held to the same standards of confidentiality as our therapy. If any given question does not apply to you, please put down “n/a” or “none.”
You will also need to confirm at the end that you have read the Good Faith Estimate Disclosure.
PATIENT DETAILS
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