Carol Fizer licsw, msw

Psychotherapy for individuals, couple, and families of all ages

Intake Form

Step 1 of 3

INFORMATION ABOUT YOU
Date
Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Address*
Street Address City State ZIP Code
Cell Phone*
Email

Insurance Policy Holder*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Address (if not the same)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Are you using EAP benefits?*
- Yes
- No
Authorization Number
EAP Name
Employer
Insurer*
Policy Number*
Emergency Contact*
Name Relationship Cell Phone Email

Reason for Appointment*
Questions You Have
Name
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