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Intake Questionnaire
Welcome, new Clients! Thank you for your interest in TL Solutions. Please complete this form in its entirety to get started.
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* Indicates required question
1. Name
*
First and Last Name
Your answer
2. Date of Birth
*
MM
/
DD
/
YYYY
3. Email
*
Your answer
4. Phone number? When is the best time to contact you?
*
Your answer
5. Race/Nationality
*
Your answer
6. Address
*
Your answer
7. Do you have insurance? If so who is your insurance provider? What is your insurance number? (Information is utilized to verify coverage and determine Copay responsibility)
*
Your answer
8. What is your current issue? How long has this issue been going on?
*
Your answer
9. Do you currently have any legal issues? Are you or your child involved in litigation?
*
Your answer
10. Have you filed a restraining order against anyone? Has anyone filed a restraining order against you? Is anyone harassing or stalking you?
*
Yes
No
11. Why do you want to work with me? How did you hear about my practice?
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Your answer
12. Have you ever had Therapy before? If yes, when? With who? Why did you stop?
*
Your answer
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