New Therapy Client Intake Form

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Welcome! We're so happy you found us :) If you're ready to take that first step, just fill out this form and we'll get started...

New Client Intake

First name*

Last name*

Email*

Phone*

Client's Date of Birth*

How would you prefer to be contacted?*

Phone

Text

Any of the above

I am looking for...*

A therapist just for me

Couple's therapy

Therapy for one or more of my children

Equine therapy

Groups

I prefer to meet*

In person

Online

I'm flexible

Qualities I look for in a therapist include....

A sense of humor

Someone who listens without interrupting

Someone who challenges me

Someone who is good at problem solving

Someone who provides structure

Someone who gives good feedback

Someone involved in the LGBTQ+ community

Someone who is positive

Someone who is nuturing

How did you hear about us?*

A Key Therapy Client

My Doctor or APRN

A Google Search

A Family Member or Friend

Someone from My Child's School

Other

If you were referred by your PCP, what is their name?

Name of Insurance:*

Member ID:*

Group RX Number:*

Days/times you are available:*

Country/Region*

Address*

City*

Zip / Postal code*

Are you a veteran or an active member of the military?:*

Do you have a history within the last 6 months of suicide attempt?:*

Are you currently involved in any legal disputes?:*

Are you currently in a household that is experiencing domestic violence?:*

If you are seeking services for your child, please describe the marital and custody status of the child's parents. Is DCF involved?:*

Tell us a little about you, and your situation to help us match you with the right person:

Keep me in the Loop! I'd like to learn more about upcoming events and services!

Key Therapy Counseling

Call: 203-261-7090

or email:

contact.us@keytherapyllc.com

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Welcome! We're so happy you found us :) If you're ready to take that first step, just fill out this form and we'll get started... New Client Intake

Welcome! We're so happy you found us :) If you're ready to take that first step, just fill out this form and we'll get started...

New Client Intake