Adult Intake Form 

Please fill out the form below, skipping any optional questions you would rather not answer. Questions followed by an asterisk are required. No need to print, just click the submit button at the end. Thanks!

Date *
Date
Name *
Name
Best phone number for me to reach you at. *
Best phone number for me to reach you at.
Mobile phone
Mobile phone
Are you reachable by text
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?
Women: check box if pregnant
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.