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: 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
    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

      MM slash DD slash YYYY
      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