INTAKE FORM

Please take some time by yourself to answer these questions to the best of your knowledge, as of today.
This form is meant to be a comprehensive understanding of your current life experience and background.


PERSONAL INFO
Name *
Name
Name of Parent/Guardian (If client is under 18)
Name of Parent/Guardian (If client is under 18)
Address *
Address
Cell Number *
Cell Number
Note: Texting is not considered a confidential method of communication
House Number
House Number
Date of Birth *
Date of Birth
Marital Status *
Partner's Name
Partner's Name
Names, ages, gender & any significant problems with any of these children?
THERAPEUTIC INFO
Check any that apply to you. *
In childhood AND as an adult
Better yet, do you have any free time?
What is the last grade of school that you completed? Scholastic abilities: strengths and weaknesses? Were there any problems with truancy, suspensions, special education, vocational training, etc.?
Have you seen a Psychotherapist previously? Medications? If so, please list name and dosage
SELF-DESCRIPTION
Complete the following statements. Don't think to much, just type the first thing that comes to mind.
How did you find me?

I appreciate you taking the time to fill this out.

Note: Payment is expected for any missed session, unless the appointment is cancelled at least 36 hours in advance. 

Directions: Kayla is located on the 3rd floor of the 1954 Angus St building. You can park on either side of Angus (in front of the building - parking is free for 2 hours). Enter the building from the front - come up to the stairs to the third floor. The door signage says Red Fox Creative Studio.

About the STUDIO: FYI - Kristin (Kayla's business partner) may be working in the studio. The space you will walk into is a large studio (EAST STUDIO), Kayla's office is in the middle of  the studio.
 You can have a seat on the teal couch in the WEST STUDIO and Kayla will come and get you.