Client Intake FormClient Intake Form • October 3rd, 2019
A scheduled appointment is a commitment of time between you and our practice. We have reserved that time just for you and that time is valuable. When appointments are missed or cancelled, that time is permanently lost.
Client Intake FormClient Intake Form • October 3rd, 2019
A scheduled appointment is a commitment of time between you and our practice. We have reserved that time just for you and that time is valuable. When appointments are missed or cancelled, that time is permanently lost.
DATE: _____________________Client Intake Form • March 13th, 2008
May we leave a message at the above numbers? If no, please indicate Place of Employment/Job Title: How long have you been employed there?
Success Strategies Unlimited, Inc Jennifer Dunham, LPC, LPC-S, CHT Client Intake FormClient Intake Form • December 28th, 2021
A session lasts 45 minutes; a half session lasts 25 minutes. Full payment is expected at each session. Your session time is reserved for you. There is a charge of $165 for appointments not kept, canceled, or rescheduled within 24 hours for any reason. This fee is NOT billable to insurance companies. Phone consultations over 5 minutes are charged at the rate of $3.00 per minute for the full duration of the call. A fee of $35.00 is charged for returned checks.
PHOENIX BEHAVIORAL HEALTH SERVICES, LLCClient Intake Form • June 9th, 2022
LAST NAME FIRST MI PHONE BIRTH DATE AGE ADDRESS SS# MALE FEMALE CITY STATE ZIP MARTIAL STATUS - SINGLE MARRIED. WIDOWED DIVORCED EMAIL ADDRESS- required Client Employer DESCRIPTION OF PROBLEM WHO REFERRED YOU FOR MINOR CLIENTS - IS THERE A CUSTODY AGREEMENT - YES (Please provide a copy) NO HOW DID YOU HEAR INTERNET DR. REFERRAL PERSONAL REFERRAL ABOUT US? (check) COURT ORDERED INSURANCE PPO LIST OTHER (please list) EMERGENCY CONTACT PERSON RELATIONSHIP PHONE SPOUSE OR PARENT(S) NAMES SPOUSE'S OR PARENTS EMPLOYER PHONE GUARDIAN NAME GUARDIAN ADDRESS GUARDIAN PHONE
Professional Consulting, Coaching, Critical Incident Response, Psychotherapy, and HypnotherapyClient Intake Form • September 29th, 2022
Phone consultations over 10 minutes are charged in 15 minute increments at the rate of $3.75 per minute for the full duration of the call. A fee of $40.00 is charged for returned checks.
Success Strategies Unlimited, Inc Jennifer Dunham, LPC, LPC-S, CHT Client Intake FormClient Intake Form • July 20th, 2019
A session lasts 45 minutes; a half session lasts 25 minutes; a double session lasts 80 minutes. Full payment is expected at each session. Your session time is reserved for you. There is a charge of $150 for appointments not kept, canceled, or rescheduled within 24 hours for any reason. This fee is NOT billable to insurance companies. Phone consultations over 5 minutes are charged at the rate of $3.50 per minute for the full duration of the call. A fee of
Information AgreementClient Intake Form • November 3rd, 2021
CONTACT INFORMATIONTo Be Completed By Client Name Mobile Phone Number OK to leavemessage I would like to receive text notifications regarding my account, including (but not limited to) appointment confirmations. (Messaging & Data Rates may apply)I would like to receive promotional e-mail, phone calls, text messages, faxes, and other electronic messages for Elements Massage, including gift card offers, etc. (Messaging & Data Rates may apply) Address City/State Zip Email Address Date of Birth Emergency Contact Name & Phone Number ELEMENTS MASSAGE® POLICIESPlease review and check each box. (Please ask us if you have any questions, concerns or need additional information): I may undress to my comfort level. I will be properly draped, meaning covered by the sheet and/or blanket at all times. The therapist will only uncover the part of the body that is being worked on during the massage session.As further explained below, the therapist reserves the right to terminate the session at any t
Name _____________________________________________________ Date of Birth __________________________________ Street Address _____________________________ ______________________________________________________________ City...Client Intake Form • December 7th, 2016
I, ________________________________(PRINT NAME) understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this massage session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all
