A hard copy of this agreement will be provided to you.

PLEASE READ THIS SECTION THOROUGHLY BEFORE STARTING THE INTAKE OR ANSWERING QUESTIONS:

Estimated time to complete all pages is approximately 30-45 minutes (possibly more) depending on required sections of the intake and provided that all requested information is available to you while completing this form (psychological and medical history).

Refresh or reload the page to clear the form and start over. if necessary.

There is no save form feature, so you will NOT be able to save entered data, so please complete when you have the allotted time available, and feel you have information necessary to complete form.

Please provide the following information and answer "ALL" the questions of the intake. Please input NA or None, if not applicable on any required question. Please note: All the information you provide here is protected as confidential information on a secure and encrypted website that will only be viewed by the therapist. "ALL" general intake questions are "REQUIRED" by the therapist for an accurate assessment, and must be answered to request an appointment. Although there are a lot of questions, all are very relevant and necessary for appropriate treatment.

Please also note that if you don't know an exact date on the physical, dental, hearing and vision exam questions, it is okay to estimate!

Financial Assistance questions are optional, and only required if requesting a sliding fee scale.

**If you are competing this intake for ESA Disability and Treatment Recommendation Letter Service, please be sure to complete all intake questions sections and the last/required ESA section in its entirety. Please note that you can skip the Financial Assistance section, as a sliding fee scale is not available with this service due to the additional clinical requirements and service.

If you are not requesting ESA Letter Service, that section can be skipped.

PLEASE BE HONEST AND COMPLETE IN YOUR ANSWERS AND DO NOT SUBMIT AN INCOMPLETE OR FALSE INTAKE, AS IT WILL NOT PROVIDE THE THERAPIST WITH THE INFORMATION TO PROVE A COMPREHENSIVE AND ACCURATE ASSESSMENT!

These questions are NOT required. Please answer the following question if you would like to apply for reduced rates:

If you do not want to apply scroll down and click the next button.
Please note that a sliding fee scale is not available for requested ESA Letter request, as it is an additional service and requires other therapeutic services.

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