New Client Intake

Please correct the errors described below.

Please provide the following information and answer the questions below. Please note that the information you provide here is protected as confidential information.

Your Basic Information

First Name

Last Name

Address

City

State

Zip Code

Date of Birth

Current Age

Marital Status

Never Married Married Domestic Partner Separated Divorced Widowed

Please list any children and their age.

Name of Parent/Guardian

Only required if minor.

Your Contact Information

Cell Phone

May I leave a message?

yes

Home/Work Phone

May I leave a message?

yes

Email Address

Other Health/Service Provider Information

Full Name

Provider Role

Phone Number

Address

Emergency Contact Information

Full Name

Relationship to Patient

Phone Number

Address

Referred By

Phone Number

Your information will be encrypted.

Carol Park LPC, RD, LD, CEDRD

469.324.9744
recoveryreconnection.com
1702 N. Collins Blvd., Suite 207, Richardson, Texas, 75080

Electronic signature

Your browser does not support capabilities required for electronic signatures.

Loading templates...

Use existing signature
Type the signature
Draw
Upload an image

Click a signature you want to use:

Clear

Drop image file here or click to select file Click here to select image file from your computer

I request that my signature be represented by the above electronic signature and consent to recipients of electronic documents that I sign receiving personal information about me, including my email and IP addresses.

Use this signature or Cancel

Hushmail

Hide