fcf intake form

So that we can better serve you, we ask that all clients fill out our intake form. Please fill out the basic information online intake form below and select “SUBMIT”. Then click here to download the printable medically confidential intake form and bring it with you to your first appointment OR go over it with your therapist during your first video session (if you have filled out and submitted the basic information online form, you do not need to fill out the FIRST PAGE of the download form as they are essentially the same. We look forward to meeting with you!


Name *
Name
Home Address *
Home Address
Cell Phone *
Cell Phone
Can we text you at this number?
Can we leave a message at this number?
Home Phone
Home Phone
Can we leave a message at this number?
Work Phone
Work Phone
Can we leave a message at this number?
Ethnicity
Are you currently in school?
Emergency contact phone number *
Emergency contact phone number
Relationship status: *
How did you hear about Florida Counseling Foundation?

By clicking on the "SUBMIT" button above, you understand that it is customary to pay for services when rendered. You accept full responsibility for payment of any balance incurred for services. You further understand that there will be a $50 cancellation fee without a 24-hour notice (except in the case of an emergency).