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HOME
COUPLES
COUNSELING
OTHER
SPECIALTIES
Family Therapy
Individual Therapy
Premarital Therapy
Infidelity Therapy
Therapist Support
ABOUT
About CCCF
About Jonathan
About Courtney
About Kate
About Alice
About EFT
FAQ’s
BLOG
LOCATIONS
South Denver
Westminster
Fort Collins
Telehealth
CONTACT
Intake Form – Individual
Jonathan Zalesne
2021-04-09T07:22:52+00:00
Individual Intake Form
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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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?
*
Select...
Referred by a therapist
Referred by a friend
I met Jonathan Zalesne in person
Psychology Today Website
Goodtherapy Website
Theravive Website
ICEEFT Website
Marriage Friendly Therapists Website
Google Search
Bing Search
Other Internet Search
Other
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
.
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