Denise O’Doherty Client Intake Form

Please fill out the information below completely prior to your first appointment.

* - Indicates Require Field

First Name*:  
Last Name*:  
Email*:  
Street Address*:  
City*:  
State*:  
Zip*:  
Home Number*:  
Work Number:  
Cell Number:  
Date of Birth*:  
SSN:  
Education*:  
Occupation*:  
Current Employer*:  
How Long At Present Employment*:  

Health Issues:  
Please List Any Prescription Meds You Are Taking:   
Addictions: (drug, alcohol, food, love, sex, spending, gambling, cigarettes, other)  
If in recovery, how long?  

Relationship Status*:  
If Married
How Long Have You Been Married:  
How Long Did You Know Each Other Before Getting Married:  
Where does your spouse/ partner work?  
Spouse's Occupation?  
If in a Dating Relationship:
How Long Have You Known Each Other?  
If Applicable, How Long Have You Been Living Together?  
If Previously Married, How Long Were You Divorced/ Separated Prior to the Relationship You Are in Now?  
List any prior marriages and length:
How many times?  
How long did each marriage last?  

Children Who Live In Household:

Please Include Names and Ages  
Pets In Your Home:  

Reason for Visit*:  
Referred By*:  
 
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