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Initial Client Intake Forms
Lex Burgeson, Master Level Splankna Practitioner
Download, complete, sign, date and bring each of these forms to your first appointment:
INTAKE Form: Please print and sign
DISCLOSURE STATEMENT: Please print and sign. If the client is a teen the age of 12 or over, he/she must ALSO read and sign this form.
PAYMENT POLICIES: Please print and sign.
HIPPA ACKNOWLEDGEMENT: Please print and sign
HIPPA DOCUMENT: Please read. Print ONLY if you'd like to keep a copy for your records.
CONSENT TO TREAT MINOR CHILDREN (for children under age 15)
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