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‘From Under the Rug’ Mental Health Therapy Intake Form
This form will ask you general questions and provide your therapist with a brief overview.
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* Indicates required question
First Name Last Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Residential Address
*
Your answer
Email Address
*
Your answer
Phone Number
*
Your answer
What is your preferred contact method? (Text is easiest and fastest way to communicate. E-mails will definitely come in the form of PayPal messages for invoicing, calendar invites for sessions, and notifications about changes with the practice.)
*
Email
Phone
Text Message
Voicemail
Required
Emergency Contact Name
*
Your answer
Emergency Contact’s Phone Number
*
Your answer
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