New Client Intake Intake Form ← BackThank you for your response. ✨ Full Name(required) DOB(required) Pronouns Age(required) Street address(required) Address line two City(required) State(required) Zip code(required) Primary phone (required) Can you receive texts at this number?(required) Yes No May we leave voicemail messages at the phone number provided above?(required) Yes No Email(required) Marital Status Single Married Divorced Widowed Domestic partners How did you hear about us? Internet Psychology today Professional referral Friend Family referral Insurance information Will you be using insurance?(required) Yes No Name of Insurance(required) Policy Holder DOB My insurance policy is in someone else’s name (partner, spouse, etc.) Policy Number Group Number Employer of Policy Holder Please attach photo of front and back of insurance card Emergency contact first and last name Relationship Phone Email Authorization for release of information for billing and administrative purposes I hereby authorize the release of any information necessary for client intake, third-party claim submission and/or payment for services. I authorize payment of third-party benefits to Relentless Resilience Psychotherapy, Consulting, and Supervision, PLLC for services described herein. I understand that I am responsible to pay for all sessions, including failed appointments. A failed appointment is a missed appointment or cancellation with less than 48 hours’ notice. The charge for a failed appointment is the full cost of the session. I understand that my insurance company will not be billed for failed appointments. By entering my initials below, I agree to the terms and release above * Initials Please give a brief description of what you are hoping to work on in therapy. This will remain confidential: (required) SendSubmitting form Δ
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