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All information on this form is considered confidential and will not be shared with anyone other than your therapist unless permission is granted through written consent.

This form is form is for immediate printing - information will not be stored online. If you would rather print a form and manually fill it out please download the PDF version.

Client Details

May we leave a message?

Spouse/Partner Details

Children/Household Members

Referral Information

How did you find out about Refection Therapy Services?

Physician Contact History

Are you currently under the care of a psychiatrist?

If yes, please enter the psychiatrist you are seeing:

Psychotropic Medication History

Therapy Experience

Have YOU ever received mental health services (counseling/therapy) in the past?

If YES...

Immediate Family Members

Have any of IMMEDIATE FAMILY MEMBERS listed on this form received mental health services (counseling/therapy) in the past?

If yes:

All information on this form is considered confidential and will not be shared with anyone other than your therapist unless permission is granted through written consent.