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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:  ____________________________  


Consultation Form