SIMPLE INTAKE FORM

Today's Date*

First name*

Last name*

Email*

Cell Phone*

Reason for Today*

Check as many of these that relate to you. (be honest)

I can't shut my brain off.

I am always anxious.

I struggle with fear.

I have an addiction.

I have no friends.

I have suffered abuse (sexually, emotionally, physically).

I have an anger problem, so I'm told.

I hate to look at myself in the mirror.

I am always sad.

I take mental health medication.

I hate myself.

Anything Else?

bottom of page