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.
A PDF Registration Form is also available for filling out offline.

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.