Therapist Client Intake Form

Information you will need

• Do you want to upload the Clinic's logo? af image
• CLINIC ONLY: What’s your name or the name of your clinic?
• What’s today's date?
• CLIENT ONLY: What’s your name?
• What’s your birth date?
• What's your age?
• What's your address?
• In what city do you live?
• What’s your ZIP code?
• What's your cellphone number?
• May the clinic phone your cellphone?
• May the clinic leave a message on your cellphone?
• May the clinic text your cellphone?
• What's your secondary phone number?
• May the clinic phone your secondary phone?
• May the clinic leave a message on your secondary phone?
• May the clinic text your secondary phone?
• What's your email?
• Do you prefer being contacted on your cellphone?
• Do you prefer being contacted on your secondary phone?
• Do you prefer being contacted by email?
• Do you prefer being contacted by mail?
• Is there another way you’d prefer to be contacted?
• What's your preferred method of contact?

…and 110 more fields in the PDF.

Completed by the provider and the client and the employer.

The form includes 1 signature line, a notary acknowledgment.