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:**


Please Enter The Characters Above in the Box Below

Denise O’Doherty Client Intake Form