Distance Treatment Intake Form

Please fill out the form below, skipping any optional questions you would rather not answer. Questions followed by an asterisk are required. Click the submit button at the end. In addition, text or email me a recent photo of yourself before our scheduled meeting time.

If you will be coming to my office for an in-person treatment, please fill out the Adult Intake Form or Child and Teen Intake Form instead.

Date *
Date
Name *
Name
Best phone number for me to call you on at appointment time? I can also Skype (audio only) for free calling locally and internationally. *
Best phone number for me to call you on at appointment time? I can also Skype (audio only) for free calling locally and internationally.
Cellular number for texting?
Cellular number for texting?
http://
Please list ages
If yes, please explain a little.
Are you currently working with a therapist or counselor?
Have you been experiencing any of the following during the past year?
Do you currently have any of the following?
I agree to give at least 24 hours notice should I need to cancel or reschedule a session, and pay for sessions cancelled or missed without such notice. *
Terms and Conditions *
Ko Darlington is not a licensed medical doctor nor licensed psychologist and does not practice any form of licensed medicine or psychology. He does not diagnose, cure, heal, treat disease or prescribe medication. He will not be held responsible for any damages or losses. It is recommended that clients continue to seek the advice of a licensed physician for medical conditions.