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PATIENT INTAKE FORM
Email
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Patient's First Legal Name
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Patient's Last Legal Name
*
Patient's Date of Birth
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Day
Month
Month
Year
Who is filling out this form?
*
Patient
Parent
Child
Partner
Friend
Other:
Best Contact Number
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Patient's Home Address
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Select Patient’s State
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Briefly: what made you/the patient want to begin therapy?
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Are you seeking a particular type of therapy?
Talk Therapy
CBT (Cognitive Behavioral Therapy)
DBT (Dialectical Behavior Therapy)
Trauma Therapy
EMDR (Eye Movement Desensitization and Reprocessing)
Couples Therapy
Family Therapy
Children’s Therapy
Anger Management
Addiction Counseling
Grief Counseling
Unsure
Are you seeking a particular type of therapist (i.e., any personal or professional characteristics)?
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Please upload a photo of the front of your insurance card for insurance verification.
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Upload File
Please upload a photo of the back of your insurance card for insurance verification.
*
Upload File
How did you hear about us?
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Google search
Alma
Psychology Today
Insurance panel
Referral from another therapist/Doctor’s office
LACPA
Recommended by our existing client
Other
Anything else you would like to share?
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