NEW CLIENT INTAKE FORM

Please fill out this form and submit it prior to your first session. It helps us to determine your co-pay or out-of-pockets costs.

Also, please email me a copy of both sides of your insurance card to stephaniejohnsontherapy@gmail.com.

Date

YYYY

Insurance Company

Group Number

Policy Number

Client's Name

First Name

Last Name

Client's Birth Date

YYYY

Gender

Male

Female

Other

Client's Current Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Preferred Phone

(###)

###

####

May I leave a message?

Yes

May I email you?

Yes

If client is under eighteen years of age, please list a parent or guardian.

Guardian's Name

First Name

Last Name

Guardian's Phone

(###)

###

####