Emi M Whittle, LPC, PLLC	Initial Intake

Please take care with where you complete and save this form, as its privacy is your responsibility. Only email it using encrypted email, preferably a free account at www.hushmail.com. Submitting this form is acceptable ONLY after you have completed and signed and returned (accompanying this document is acceptable) the Informed Consent and Privacy Notice forms.

Today’s Date: ____________

Name (Last, First, Middle): ______________________________________________________________

Date of Birth: _______________________ Driver’s License or SSN: ________________________

Physical Address: ______________________________________________________________________

City, State, Zip: _______________________________________________________________________

Gender: Male or Female Marital Status: _________________________________________________

Hushmail address: _____________________________________________________________________

Secondary email address: ________________________________________________________________

Home Phone:_______________________ Cell Phone: ______________________________

Please state YES, to give permission to be contacted via your:

hushmail email address: _____	Secondary email address: _____

Home Phone: ____	Cell Phone: ___	By Mail: ___

Have you ever been convicted of a crime?_____ If so what and when: ___________________________

Alternative Contact Information: (This information will be used only for Emergency contact needs.)

Name of an emergency contact(s) if you cannot be reached:___________________________________

Relationship to you: ____________________________________________________________________

Phone numbers: _______________________________________________________________________

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Do you have experience with (check or x if yes):

Email ___	Encrypted Email or Chat ___	Chat/Instant Messaging ___

PayPal ___	Internet Use ___	Windows XP/Vista/7 ___

What type of Internet access do you have (check or x):

Dial Up ___	Broadband ___

Have you ever been in counseling before? If yes, when, how long, and for what problems? What was the outcome?

Are you currently being treated by a therapist, counselor or psychiatrist?

Are you currently taking any medications, even OTC? If yes, please list them/purpose:

Please give me a brief idea of your current issue that brings you to counseling, any background or current circumstances you feel may be relevant, and anything else you think might be useful to counseling:

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AGREEMENT: I have read and completed all information truthfully and accurately to the best of my knowledge. I have read and accepted the Informed Consent and Notice of Privacy Policies and agree to all terms of services.

Printed Name:

Signature: ________________________________

Date: ____________________________________

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