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GENERAL INTAKE FORM
Please note that all information provided is kept private and confidential
Legal Name
Name you go by
if different from legal name
Date of birth
day/month/year
Gender
Pronouns
he/she/they
Address
street, city, postal or zip code
0
/
Phone Number
to best reach you
Can you be contacted by text?
Yes
No
Is it ok to leave a phone message?
Yes
No
Email
Is it ok to leave an email message?
Yes
No
Emergency Contact
name and relationship with them
Phone Number
emergency contact
Current Relationship Status
if you are in a relationship(s)
Years with current partner
if applicable
How did you find this service?
internet, referral, friend, etc.
Have you sought out general counseling, therapy or coaching before?
Yes
No
Unsure
If you plan couple/relationship therapy
please state their name(s)
If you plan couple/relationship therapy
please state their name(s)
What do you think would be a helpful/unhelpful therapy, counselling or coaching experience?
0
/
If you are being treated by a medical or mental health health provider for a related health matter
provide their name and related issues being addressed
0
/
Please list any medications / herbs / supplements
provide conditions being treated, dosing and side effects (if any)
0
/
Please share any chronic or acute health matters that can have an effect on your health or relationship(s)
share as much as you feel comfortable
0
/
What are your therapy / counseling / coaching hopes and goals?
share as much as you feel comfortable
0
/
Is there anything in particular that is important to know about you?
share as much as you feel comfortable
0
/
Have you read the Fee, No Show, Cancellation Policy?
I agree with all policies stated https://reecemalone.com/policies
Yes
No
I would like to discuss this further
Have you read the Limits of Confidentiality Policy?
I understand the limits of confidentiality https://reecemalone.com/policies
Yes
No
I would like to discuss this further
Have you read the Informed Consent for Phone and Online Video Sessions Policy?
I understand the informed consent for phone and online video policies https://reecemalone.com/policies
Yes
No
I would like to discuss this further
I acknowledge that electronic communication (email/texting) is not 100% secure. My initials is my consent to being contacted electronically
please add your initials
Submit Form
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