New Client Intake Form
Thank you for taking the time to fill out the intake form for Katy Pavlis, LMT and Words Between Worlds.

There are five sections: 1) Basic information 2) Health History 3) Office Policies and Etiquette 4) HIPPA Privacy Policies Notice 5) Informed Consent.

It should take you about 10 minutes to fill out this form.
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Email *
First, Middle, and Last Name *
Preferred Name *
Pronouns (i.e. She/Her, They/Them, etc.) *
Date of Birth *
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DD
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YYYY
Telephone Number *
Address *
Emergency Contact: Name and Phone Number *
Referred by: *
Please describe what you would like to address during your session: *
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