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Client intake for therapy

Fill this out to register as a client

Client Intake Form

New clients must fill out this form. If you are a couple, enter information for each person as a separate submission, and list your partner's name on your form for cross referencing.

If client is a child, fill in all the details, and put parents name as cross reference in the relevant box.

All information is strictly confidential. We do not, under any circumstances, give your information out to any 3rd party.

Client details

Fields marked in bold are needed.

First Name*

Last Name*

Email*

Contact phone number*

Home phone

Work phone

City*

Street address*

State*

Postcode*

Country*

Date of Birth*

Skype name

 Notes - and how you heard about us*

If a couple, name of partner; if a child, name of parent

Full Name

Contact in case of emergency

Emergency contact name*

Emergency contact phone*

Nominate therapy fee you will be paying

(see guide here)

Nominated fee per hour*

Agreement and completion

 Check to indicate agreement to having read and understood the disclosure statement*

Yes, I have read, understand and agree to the Informed Consent statement, including the cancellation policy

No, I do not agree

Insert todays date*

Please answer the following question:

2 + 2 =

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