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 ACKNOWLEDGEMENT

 

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

©YOUnify Counseling