Journey Into Wellness Counseling Intake Form
Julie Wells LCSW, CP, TEP
Journey Into Wellness Counseling Services                 26133 US Hwy 19 N #306 Clearwater, FL 33763
727-688-5800       Fax: 727-286-9640                            PO Box 464  Crystal Beach, FL 34681
journeywellness@aol.com

This office is an English-speaking only office. NO WEAPONS PERMITTED ON PREMISES. 
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Email *
Name
Age & Gender
Date of Birth
MM
/
DD
/
YYYY
Insurance Company and Insurance ID Member #
Social Security #
Relationship Status; quality of the relationship
Number of children; ages; are they living with you; any other information that you would like to share about children
Partner's name
Your occupation; any information you would like to provide about your occupation 
Address (including zip code) *
Home phone number (including area code)
Cell phone number (including area code)
Which number is the best place to leave a message?
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Referral by:
Emergency contact (name, relationship, and phone number)
Please consent that the above person can be contacted in case of an emergency.
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