Intake Form Individual - Colorado Center for Couples and Families

Individual Intake Form
Name*
First Name Last Name
Nickname*
What would you like me to call you in therapy? For example, if your first name is Jonathan but you would prefer to be called Jon, type Jon here. If you just want me to use your first name, retype your first name here.
Email address*
Enter Email Confirm Email
Cell Phone*
If you have no cell phone, enter the best phone number to reach you.
Gender identity*
For example: Male, Female, Trans-man, Trans-woman, etc...
Birthday*
Month
Day
Year
Home Address*
Street Address Address Line 2 City State ZIP Code
Briefly describe your hopes for our work together, and your goals for therapy.*
If you are having suicidal thoughts, or have any thoughts or intent to harm yourself, please explain:*
How did you find us?*
What is this person's name?*
May I thank this person for the referral?*
- Yes, you may thank them for the referral
- No, please do not let them know I contacted you
What were the factors that influenced you to consider choosing us as your therapists?*
Agreement*
- By checking this box and clicking the Agree and Submit button below, you (1) give us permission, on the phone number provided in this form, to call and text you, and to leave voice mails in which we identify ourselves, (2) give us permission to e-mail you at the e-mail address provided in this form, and (3) acknowledge and accept our privacy policy.

Individual Intake Form