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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