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Potential Patient Information Form
Please do your best to complete all sections. Leaving many items blank will slow down the intake session.
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* Indicates required question
Legal Name:
*
Your answer
Preferred Name (if different):
Your answer
Age:
*
Your answer
Date of Birth:
*
Your answer
Mailing Address:
*
Your answer
Ok to mail treatment related information?
*
Yes
No
Preferred Phone Number:
*
Your answer
Ok to leave voicemail?
*
Yes
No
Email:
*
Your answer
Ok to email treatment related information?
*
Yes
No
Who Referred you to Feeling Good Institute?
Your answer
May we thank that person for the referral?
Yes
No
Clear selection
Occupation (if any):
Your answer
Employer:
Your answer
Relationship Status:
Choose
Single
Married
Other
With whom do you live:
*
Your answer
Religious Affiliation:
Your answer
Ethnic/Cultural Identity:
Your answer
Sexual Identity/Orientation:
Your answer
Gender Identity:
Your answer
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