Intake and Consent Form

"*" indicates required fields

General Information

Client Name*
MM slash DD slash YYYY
MM slash DD slash YYYY
Address*
Enter your EAP Name & Authorization number here. If you don't have it, please bring it to your first session.
Drop files here or
Accepted file types: jpeg, jpg, gif, png, pdf, Max. file size: 256 MB, Max. files: 2.
    MM slash DD slash YYYY
    Drop files here or
    Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB, Max. files: 2.
      Please upload the front and back of your insurance card
      MM slash DD slash YYYY

      Emergency Contact Information

      Name

      Health and Medical Information

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      Employer Name
      Address

      Additional Information

      Name*
      MM slash DD slash YYYY
      Consent by Legal Guardian (if under 14 years old)
      MM slash DD slash YYYY