EmailMe Form - Client Intake Form

Date Time

MM / DD / YYYY

Name

First Last

Phone

### - ### - ####

Email

Ok to leave a message at the above contact info?

Age

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Why Are You Seeking Therapy?

Current/Past Medical Conditions

Current Medications

Check all that apply to you or your immediate family (parents, siblings, grandparents)

Check all symptoms you are currently experiencing

Are you currently pregnant, or is there a possibility that you are pregnant?

Yes

No

Are you currently using or do you have a history of tobacco use?

Yes

No

Are you currently using or do you have a history of illegal drug use?

Yes

No

Do you feel you are at risk for falls or falling injuries?

Yes

No

Please describe your alcohol consumption

Date Time

MM / DD / YYYY

Primary Doctor

Current Relationship Status

Long Term/Committed

Married

Engaged

Divorced/Remarried

Employer

Occupation

How Did You Hear About Couples Thrive?

Past/Present Therapy (specify: month year(s) (beginning—end), estimated no. of sessions, name, initial reason for therapy, description of the relationship and how helpful it was, and how/why it ended):

Children (Name & Ages)

CANCELLATION
Since the scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours (1 day) notice is required for re-scheduling or canceling an appointment. If an appointment is canceled within the 24 hour period leading up to your scheduled appointment time or you miss the appointment, you will be charged 100% of our agreed upon fee unless there is an opportunity to reschedule within that same week (7 days from the time of the missed appointment). However, this is at the discretion of the therapist.

Credit Card

Billing Zipcode