• ADULT INITIAL PSYCHOTHERAPY INTAKE

    Please provide the following information and answer the questions below. Please note: the information you provide is protected as confidential information. Please fill out this form and bring it to your first session.
  • Part One:

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  • *Please note: E-Mail correspondence is not considered to be a confidential medium of communication.

  • Part Two:

  • Privacy and Rights Acknowledgement

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  • By signing below, I am acknowledging that I have read and understand the above policies. Paper or electronic copies can be obtained by request. 

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  • Payment Acknowledgement Agreement

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  • By signing below, I understand and agree to the above statments. I authorize my insurance benefits to be paid directly to Hope for a Better Tomorrow.

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  • Health Risk Assessment

    Please circle the number which best identifies your response to each corresponding question-1. Never or Almost Never; 2. Occasionally;3. Often;  4. Very Often; or 5. Always or Almost Always
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