Therapist Intake Form

Therapist Intake Form

If you have been approved to be a therapist at Guttman and Pearl Associates for mentorship, coaching or supervision services, please fill out this form and acknowledge receipt of all notices here within. We look forward to working with you.

Name(Required)
Date of birth(Required)
Sex(Required)

Gender Identity(Required)

Address(Required)
Emergency Contact(Required)

Section Break

ESign, Cancellation Policy, Privacy Practices, Self-Pay Agreement

You agree that your signature for this electronic document is valid and will be enforceable as and to the full extent of a hand-written signature as an original for this entire New Client Intake Form, including all sections and checkboxes here within. BY TYPING YOUR FULL NAME BELOW, you agree to this E-Sign Acknowledgement and Agreement.
Cancellation Policy(Required)
SELF-PAY AGREEMENT(Required)
NOTICE OF PRIVACY PRACTICES (EMAILED TO YOU UPON SUBMISSION OF THIS FORM): THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.(Required)
By SIGNING YOUR FULL NAME BELOW, you e-sign and agree that all information is yours, true and accurate. You also e-sign and agree to all acknowledgements and agreements within this document. Lastly, you e-sign and consent to therapy services as discussed with your therapist, including therapy session fees.
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