New Client Intake Form If you are a new client, please fill out this form prior to contacting me. Thank you! Name* First Last Are you filling this form out for your child?*NoYesIf so a field for your child's name will appear.Child Name First Last Date of birth* Date Format: MM slash DD slash YYYY Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Who referred you to me? Or how did you find me?What are your concerns at this time?How have you already addressed your concerns?Do you believe in making lifestyle changes to improve your situation?YesNoI'm not sureIf yes, what have you tried thus far?Please list care providers that you feel are an important part of you and your child’s life. And provide their contact information.What are the goals you have for treatment:Are you willing to do “homework” to attain the goals you’d like to accomplish?YesNoI'm not sureBy submitting this form, you agree to the following terms:If a client is in a situation where they may be of harm to themselves or others, it is clinical policy to ensure the client’s safety even if this involves a breech in confidence. There is a required 48 hour notice for cancellations or rescheduling to avoid charges for scheduled appointments. If a client needs or wants to end a session early, the are still obligated to the time that was scheduled. This iframe contains the logic required to handle Ajax powered Gravity Forms.