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Client Intake Questionnaire - TherapySites

Client Intake Questionnaire Please fill in the information below and bring it with you to your first session. Please note: information provided on this form is protected as confidential information. Personal Information Name:_____ Date: _____ Parent/Legal Guardian (if under 18): _____ Address: _____ Home Phone: ___ _____ May we leave a message? Yes No Cell/Work/Other Phone: _____ May we leave a message? Yes No Email: _____ May we leave a message? Yes No *Please note: Email correspondence is not considered to be a confidential medium of communication.

Client Intake Questionnaire Please fill in the information below and bring it with you to your first session. Please note: information provided on this form is protected as confidential information.

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