Protecting your privacy and health information is our highest priority. Please be assured that no information on this form will be shared without your express consent, and in accordance with HIPAA.
If you're a new client, please complete and submit this form prior to your first session. This form is confidential and will be encrypted and can only be read by Donna Kennedy.
Client Information
Include parent/legal guardian name(s) and phone numbers.
If you were referred to me please include their name so I may thank them
Emergency Contact Information
History
General 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 in the space provided (e.g. father, grandmother, uncle, etc.)
Additional Information
Signature
Type your full name
Your information will be encrypted.
Protecting your privacy and health information is our highest priority. Please be assured that no information on this form will be shared without your express consent, and in accordance with HIPAA.
If you're a new client, please complete and submit this form prior to your first session. This form is confidential and will be encrypted and can only be read by Donna Kennedy.