Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

The email you provide will be for session reminders and program details, as well as billing information. Email is not private and cannot be considered confidential communication. Do you give permission to use email for this kind of correspondence? *

Yes

No

Cell / Phone

(###)

###

####

Texting is not private nor is it considered confidential communication.

Can we call/leave a message?

Yes

No

Do you give permission to use texting for session reminders and basic information about the program?

Yes

No

Work Phone

(###)

###

####

Can we call/leave a message?

Yes

No

Have you ever been in counseling before?

Yes

No

Emergency Contact / Name

First Name

Last Name

Emergency Contact Cell/Phone

(###)

###

####