INITIAL INTAKE FORM Name * Enter your full name Email * Enter your email Address * Enter your address ZIP Enter your ZIP Country Enter your Country For Premarital Date of Wedding Name of Patient * Enter name of patient Phone * Enter your phone numbert Brief description of problem * Enter brief description of problem City Enter your city State Enter your state Referral Source * Select Referral Source Type of therapy * Select type of therapy Patient Date of Birth * Enter Patient Date of Birth Patient Date of Birth * Enter Patient Date of Birth Relationship to Patient Select relationship to patient American Indian/Alaskan NativeAsianAfrican/AmericanHispanicWhiteHawaiin/Pacific IslanderOther Phone * Enter your phone number Phone * Enter your phone numbert Brief description of problem * Enter brief description of problem City Enter your city State Enter your state Is this a Court or Immigration Case? * Select Court CaseImmigration CaseNone of the Above City Enter your city State Enter your state Relationship to Patient Select relationship to patient SelfSpouseParentOther Employer Enter Employer Employer Phone Enter employer phone number Member ID # Enter Member ID# Group ID# Enter Group ID# Patient Date of Birth * Enter Patient Date of Birth Patient Date of Birth * Enter Patient Date of Birth