Adult Intake Form NEW

Please complete the following form prior to your first appointment with us. If you have any questions, please call us at 859.554.0740.

Step 1 of 13

  • Adult Client General Information

    Please provide the following information for our records. Leave blank any questions you would rather not answer, or would prefer to discuss with your therapist. Information you provide here is held to the same standards of confidentiality as our therapy.
  • MM slash DD slash YYYY
  • Please enter a number from 18 to 100.