Adult Intake Form

The Center for Transpersonal Therapy is a limited liability company which includes licensed therapists, professional counselors, and programs that share a common Transpersonal perspective. To economize our time together, please supply the following information, read and sign the accompanying service contract.

This field is for validation purposes and should be left unchanged.

Client Name(Required)

First Last

Date(Required)

Which therapist are you scheduled with?(Required)

Address(Required)

Street Address Address Line 2 City State ZIP / Postal Code

Home Phone

Work Phone

Cell Phone(Required)

Email address(Required)

Social Security #

Occupation

Employer

Name, address, and telephone of nearest relative not living with you

Name

First Last

Phone

Address

Street Address Address Line 2 City State ZIP / Postal Code

In case of emergency, the name, address, and telephone of a person we may call

Name

First Last

Phone

Address

Street Address Address Line 2 City State ZIP / Postal Code

Please list the members of your present household

Name

Age

Relationship

Occupation

Briefly describe your reason for seeking help

Who suggested you contact us?

How would you describe your physical health at this time?

Please list any medication you (the client) are taking at thei time, their dosage, and reason prescribed and prescibing physician name and number

Medication

Dosage

Reason Prescribed

Physician

Phone

Have you ever received psychiatric or psychological help of any kind before?(Required)

yes

Please briefly explain(Required)

Who will be responsible for payment?(Required)

First Last

Phone

Address

Street Address Address Line 2 City State ZIP / Postal Code

Relationship to you(Required)

All that you are seeking is also seeking you. If you lie still, sit still, it will find you. It has been waiting for you a long time.

Clarissa Pinkola Estes

Be proud of your scars. They have everything to do with your strength, and what you’ve endured. They’re a treasure map to the deep self.

Clarissa Pinkola Estes

Yesterday I was clever, so l wanted to change the world.
Today I am wise, so l am changing myself.

Rumi

Learn from yesterday, live for today, hope for tomorrow. The important thing is not to stop questioning.

Albert Einstein

The path to our destination is not always a straight one. We go down the wrong road, we get lost, we turn back. Maybe it doesn’t matter which road we embark on. Maybe what matters is that we embark.

Adult Intake Form

Name, address, and telephone of nearest relative not living with you

In case of emergency, the name, address, and telephone of a person we may call

Clarissa Pinkola Estes

Clarissa Pinkola Estes

Rumi

Albert Einstein

Barbara Hall