Initial Client Intake Forms
Jennifer DeBrito, Master Level Splankna Practitioner
Download, complete, sign, date and bring to your first appointment:
INTAKE: If the client is a child, please enter his/her name on the "client" line. If you are bringing more than one child, please complete a form for each child.
DISCLOSURE STATEMENT: If the client is a teen over the age of 14, he/she must ALSO read and sign this form.
HIPPA DOCUMENT: Please read. Print ONLY if you'd like to keep a copy for your records.