New Client Intake Form | Journey Inward Therapy LLC

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Journey Inward Therapy — Intake Form

Please complete this intake form before your first session. All information provided will be kept confidential in accordance with HIPAA guidelines.

First name*

Last name*

Date of birth*

Month

Day

Year

Gender*

Female

Male

Non-binary

Prefer not to say

Other

Preferred pronouns

Client Address

Country/Region*

Address*

City*

Zip / Postal code*

Mobile phone*

Home phone

Email address*

Preferred contact method*

Phone

Email

Text message

Emergency contact name*

Relationship to client*

Emergency contact phone*

Mental Health Therapy

1221 Bower Parkway

Unit # 106

Columbia SC, 29201

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