fcf intake form

So that we can better serve you, we ask that all clients fill out our intake form. You can either fill out the online intake form below and select "Submit" when finished or you can click here to download the printable intake form and bring it with you to your first visit with us.


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: *
With whom do you currently live? (Check all that apply) *
Check any of the following symptoms or problems that you are presently experiencing or have experienced in the past.

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).