Client Intake Form

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Client Intake Form

New Client Information to request an appointment

Email *

Name of Client (s) and Pronoun *

Parent/ Guardian Information (if applicable)

Phone Number(s) of Clients *

Do you have a therapist preference? (If you were referred or request a specific therapist please indicate below)

Ranada Dalton, LMHC,MAMFT

Joni Morse, MAMFT

Andre Terrett, M,ED

Nicole Jones, MSW

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What prompted you to seek therapy?

Do you feel suicidal, at risk of self harm and or homicidal? If you answer No, skip the next section. *

If answered yes, do you have an action plan currently in place? (If you answered NO to previous question you can skip this section)

Please indicate how the services will be paid *

Please indicate the INSURANCE CARRIER NAME, D.O.B of the subscriber, ID NUMBER, and GROUP NUMBER for the plan. If you do not have insurance, please indicate CASH PAY on field below. If you need a scholarship, please indicate the reason why. **Pricing will be discussed on the call with the office manager/therapist once assigned. *

Please indicate how soon you would like to begin services. You can request a certain day/time. This is not a guarantee of an appointment. *

We currently offer virtual appointments. If you are looking for in person, please indicate below and the therapist will confirm the choice if available. *

Virtual (Link provided at scheduled time)

In person (Therapist will make confirm)

How did you hear about us?

Any questions about the practice? You will receive a response to the email within 24 -48 hours

Empowered Living Inc www.empoweredlivinginc.net

Send me a copy of my responses.

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