UNCG Psychology Clinic - Client Interest Form

Please correct the errors described below.
First & Last Name of potential client
Please include your name here if you are filling this form out for someone else (e.g., child, dependent)
of potential client
of potential client
Please note these forms are not monitored for safety concerns. If you are experiencing a mental health emergency, please contact 911; the Suicide & Crisis Line at 988, or the Therapeutic Alternatives Mobile Crisis Line at 1-866-626-1772 if you reside in or near Guilford County.
This is how we will contact you

Your information will be encrypted.