Forms — Anna Patience Psychology

Intake Form

This form is for new clients where an agreement has already been made to start working together. If you are interested in starting therapy, please use the contact page.

Intake Form

Name

First Name

Last Name

Pronoun/s

Phone number

Age

Date of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Physician

Primary Physician's contact number

Psychiatrist's name + number (if any)

Emergency Contact person

Please supply the name and contact details of an emergency contact (and their relationship to you).

Medical issues

Please note any medical issues I need to know about

Who referred you / Where did you hear about me?

Cancellation Policy

If you need to cancel or change your appointment, please make sure to do this no later than 24 hours beforehand. This allows for enough time for the appointment to be made available to someone else. If you miss an appointment or have to late cancel, full payment will be requested.

Confidentiality

Everything discussed in therapy is strictly confidential. The only time information may need to be divulged to a third party is if you report that you or someone else is unsafe.

Payment

Payment is expected at the time of service or no later than 7 days following our appointment. Information about how to pay is provided in the separate information form.

I have read and understood the above information.

I agree to have read and understood the terms as outlined above and in the information form (separate document).