Client Intake Forms

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Website Intake Form* 

*this form is fully encrypted.
Person making referral name:
Client Name
Address

(If under 18 years old, please provide parental information)

Parent 1 Name:
Parent 1 Address:
Medical Rights?
Parent 2 Name:
Parent 2 Address:
Medical Rights?
Any custody issues (e.g. custody disputes or lawsuits?)

If yes, please bring custody papers with you to the first appointment. For all telehealth appointments, please send hard copy via mail or drop off at the office mailbox located at the front of the building.

May we leave a message regarding you or your appointment?
Please Select All that Apply:
DANGER TO SELF OR OTHERS:
Urgency

If Emergent or suicidal, please call 911 or go to the closest crisis center. CRISIS can be reached at 814-889-2141

Disclaimer:

By providing my phone number to “InnerPeaceCounseling”, I agree and acknowledge that “Company Name” may send text messages to my wireless phone number for any purpose. Message and data rates may apply. We will only send one SMS as a reply to you, and you will be able to Opt-out by replying “STOP”.

Privacy and policy:

No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All the above categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties.