New Client Intake

"He leads me beside quiet waters.  He restores my soul." - Psalm 23:2-3
Please read the below policies and disclosures before proceeding to the Intake Form.

Confidentiality & Its Limits

Session Structure & Duration

Your privacy is important.  All information shared is confidential unless:
  • You are a danger to yourself or others
  • There is suspected abuse or neglect of a child or vulnerable adult
  • You authorize a release of information in writing
Sessions are typically 50-55 minutes long and scheduled weekly or biweekly.  Please arrive on time.  If you are late, your session will still end at the scheduled time.

Cancellation Policy

A 24-hour notice is required to cancel or reschedule an appointment.  Late cancellations or no-shows may result in a cancellation fee.

1. Personal Information





2. Emergency Contact

3. Presenting Concerns

4. Symptom Checklist (Check all that apply)









































5. Medical & Mental Health History










6. Spiritual Background
















7. Digital Consent & Agreement







8. E-Signature