Patient Intake & Agreement

Creative Depth Psychotherapy requires all patients to complete this form and agree to the Fee & Policies terms and the Notice of Privacy Practices for Seja Rachael, MA, LPC-S before treatment begins. A copy of this document will be provided to you upon request.

You may choose to fill out this online form or download and print the Client Intake Form – Creative Depth Psychotherapy and bring it with you for your appointment.

Name*
First Last
Date of first visit
Age*
Date of birth*
Address*
Street Address Address Line 2 City State ZIP Code
Primary phone*
Leave a message?*
- Yes
- No
Alternate Phone
Leave a message on alternate number?
- Yes
- No
May we email you?*
- Yes
- No
Email*
Referred by
Occupation*
Employer
Psychiatrist's name
First Last
Psychiatrist's phone
Psychiatrist's address
Street Address Address Line 2 City State ZIP Code
Current medications
Taken for
Pertinent health information*
In case of emergency notify*
First Last
Emergency contact phone
Relationship to you*
Please describe what prompted you to make this appointment.*
What have you tried to address your concerns?
Your form submission, below indicates that you have read, understood, and agree to abide by the Privacy Policy (linked above) and agree to the conditions mentioned on the Fees & Policies page. Agree:*
- Yes
- No