Client Input

For USA-based clients:

For UK-based clients:

Client Records Entry / Update

This online form (below) is provided for your convenience to complete the Client Intake Form.
Please also review and understand the information contained in the Client Intake Document (PDF).
You may also use this form to update your information.

* Indicates required field

Name *

First

Last

Telecoms

Mobile Phone Number *

Home Phone Number *

Work Phone Number *

Email *

Address

Address *

Line 1

Line 2

City

State

Zip Code

Country

Emergency Contact

Your Emergency Contact Name (next of kin) *

First

Last

Their Relationship to You *

Their Phone Number *

Identity / Status

Gender *

Ethnicity *

Relationship Status *

Childhood Religion *

Current Religion / Spirituality *

Occupation *

Time of Birth *

Date of Birth (YYYY-MM-DD) *

Place of Birth *

Source of Referral *

Social Security No. *

Driver's License No. *

Context Information

Other Members in Your Household *

Current Drugs / Medications *

Summary of Why You are Seeking Counseling *

Whom Have You Previously Consulted About the Issue(s)? *

Are You Currently Working With Another Therapist? *

Dates *

Since *

Consent to Terms & Conditions of Treatment

By signing this form as the Client (or Guardian of said Client), you acknowledge that you have read, understand, and agree to the terms and conditions contained in the Client Intake Document; and that you have been given appropriate opportunity to address any questions or to request clarification for anything that is unclear to you. You are voluntarily agreeing to receiving mental health assessment, treatment and services for yourself (or your child if said child is the client).
You consent for Empowered Maturity to communicate with you by mail, e-mail, and/or phone at the address, email addresses, and phone numbers that you are providing in the Client Information Questionnaire (Section 8.1, page 12 / or in the form above), and you will promptly advise Empowered Maturity in the event of any change.

I have read and understood the Client Intake Document. *

YES NO

Signature (Name + D.o.B.) *

Today's Date *

Option to Upload Documents *

Max file size: 20MB

Submit