CONSULTATION INTAKE FORM Eunice Baek, MFTI Marriage and Family Therapist Intern #IMF77276 Supervised and Employed by Patrick L. Healey, LMFT INC. California License #MFC30378
Please provide the following information and answer the questions below. Please note: information you provide here is protected as confidential information. Please fill out this form and bring it to your consultation Date: ________________ Name: ______________________________________________________ Name of parent/guardian (if under 18 years): ______________________________________________________________ Address: ___________________________________________________ ____________________________________________________ Home phone:(_____)________________________ May we leave a message? Y N Cell/Other Phone: (_____)___________________ May we leave a message? Y N E-‐Mail: __________________________________________ May we email you? Y N Referred by (if any): ___________________________________________________________ Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.?) Y N If yes, please provide previous therapist/Dr.: _______________________________ Previous therapist/practitioner phone number: ____________________________
Published on Mar 3, 2014
Finding a therapist who is the right fit for you is always a tricky balance. Please fill out this form if you are interested in coming into...