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CLIENT CONFIDENTIAL INTAKE QUESTIONAIRE

Please take a few minutes to relay some important information about you and what you are going through. It should only take 10-15 minutes to complete. If you are using insurance, there will be an opportunity to upload an image of your INS card at the end of this form. All information given is kept strictly confidential and will ONLY be viewed by CML staff.

Birthday
Relationship Status
Referred by:

PRIVACY AND CONFIDENTIALITY

Communication:

I give my permission to contract me (via voice or text) to the above cell phone and is a good way to remind me of appointments and to communicate minor information with me:
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