Intake Questionnaire & Informed Consent

If you are a new client please complete these forms AFTER having your initial conversation with me & we have agreed to work together. If you have not set up an initial discussion with me, please reach to me to via this contact form.

Please click the following link to view the Informed Consent for Psychotherapy. By completing and signing the form on this page you are acknowledgement receipt of this document.

Name

First Name

Last Name

Email

Phone

(###)

###

####

Are you currently experiencing any of the following: active mania, active suicidality, active psychosis?

Please list all medications and supplements you are currently taking?

How did you hear about me?

Emergency Contact Name and Phone #:

Enter Full Name for electronic signature.

By completing and signing/dating you are acknowledgement receipt of the Informed Consent of Psychotherapy linked on this page above.

Date

MM

DD

YYYY

Intake Questionnaire & Informed Consent

Marlee Dent, LPC