Adult Intake Form

Please correct the errors described below.

Personal Information

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

First and Last

*Please note: Email correspondence is not considered to be a confidential medium of communication

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    Insurance Information

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      General and Mental Health Information

      Family Mental Health History

      In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member's relationship to you (e.g. father, grandmother, uncle, etc.)

      Additional Information

      Additional Questions (Couples/Family Therapy only)

      Describe the Relationship with your Family/Significant other:

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