New Client Intake Form
Thank you for taking the time to tell me a little more about yourself and why you are seeking support through therapy. We will have the opportunity to review your answers in our initial session together. I look forward to learning more about you and am honored to join you in exploring these concerns, needs, and dreams.
Demographic Information
Legal Name (First, Middle, Last) *
Date of Birth *
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Your Sex Assigned at Birth *
Address (Street, City, State, Zip) *
Phone Number *
Email Address *
Primary Emergency Contact, Relation, & Phone Number *
Other Emergency Contact, Relation, & Phone Number
 *
Please describe your current relationship status: *
Please describe your current occupation (ie. full-time, part-time/type of work)? *
Languages spoken: *
Do you plan to submit claims to your insurance provider for mental health services provided by Leslie Jensen, LMFT? *
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