Client Intake Form – Village Therapy Group

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Mindfulness
Intake Form
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Village Therapy Group (3)

Client Intake Form

Client Intake Form

Full Name *

Date of Birth *

Email *

Phone *

Street Address *

City *

State *

Zip Code *

Reason for seeking therapy *

Symptoms *

Depression

Anxiety

Crying spells

Racing thoughts

Sleep pattern disturbance

Change in appetite

Hallucinations

Fatigue

Excessive worry

Avoidance

Loss of interest

Impulsivity

ADHD

ADD

Other

Primary Insurance Company *

Subscriber ID # *

Group Number - No Dashes

Insurance Policyholder Full Name *

Insurance Policyholder Date of Birth

Insurance Company Phone Number

Secondary Insurance Company ID #

Secondary Provider Contact Number

Emergency Contact

Emergency Contact Phone Number

If you are human, leave this field blank.

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Village Therapy Group, LLC

245 North broadway, sleepy hollow, ny 10591

For more information Email

Nicole@villagetherapygroup.com