• MM slash DD slash YYYY
  • (please note whether living in or outside of the home)

    An adult client or an adult guardian who has assumed the cost of treatment. Payment is expected at the time of service.
  • (# of siblings, marriages/significant relationships, children, impacting events, e.g. moves, developmental changes, sexual/physical/emotional abuse, trauma, divorce.)
  • Medical Information

  • (i.e. Adhd, learning disabilities, depression alcoholism, anxiety) or neurological disorders (i.e. seizures, Tourettes, autism)
  • Other care professionals you are currently undergoing treatment with including a therapist doing individual counseling or others (e.g. acupuncturist, chiropractor, medical specialists, etc.)
  • This field is for validation purposes and should be left unchanged.