Client Intake Form

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Legal Name *

First

Last

Preferred Name (if different) *

First

Last

Pronouns (Optional)

Age

Phone Number *

Email *

What are best days and times to contact you?

Address *

Address Line 1

Address Line 2

City

State

Zip Code

What insurance do you carry? *

Which of our services are of interest to you? Select all that apply. *

Do you have a counselor preference? List two if possible. Feel free to view our staff.

Have you had any negative experiences in the past with any of these services? *

Would you be willing to share a little about your experience so we can do our best to be better?

What mode of service do you prefer? *

What is your availability? *

Is there anything else you would like us to know before we connect with you?

How did you hear about us? *

Office: 208-683-8320

Fax: 208-969-8380