Mental Health New Client Registration Form
Personal Information
First Name
Last Name
Date of Birth
Gender
Female
Male
Non-binary
Other
Prefer not to say
Phone Number
Email Address
Street Address
City
ZIP/Postal Code
Emergency Contact
Name
Relationship
Phone Number
Referral Information
How did you hear about us?
Primary Care Provider (if any)
Mental Health Concerns
Please describe your main concerns
What are your goals for therapy?
Background Information
Mental health history (diagnoses, prior treatment, medications)
Relevant medical history / conditions
Allergies