Intake Form
Please answer all questions to your best ability. Please contact me via email to heather.moller@protonmail.com if you have any questions prior to your appointment.
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Email *
Name *
Date of Birth *
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DD
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Phone number *
Is this phone number mobile *
Do you want to receive reminders for your appointments? *
Will you be using health insurance? If so please select which one below. *
If you are planning to use your health insurance for psychotherapy, please share below the Group ID, Member ID, name of insured, date of birth of insured, and any other identifying info needed to check your benefits. If planning to be self-pay, just write "N/A." *
What is your current relationship status? *
Gender *
Sexual Orientation *
Current address including city, state, postal code and country *
Address where you will be attending appointments, if different from above
Emergency Contact Name, Phone Number and Relationship to You *
Alternative Emergency Contact Name, Contact Number and Relationship *
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