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Therapeutic Services
Training Center
DUI School
Contact
SMS Policies and Procedures
Home
Therapeutic Services
Training Center
DUI School
Contact
SMS Policies and Procedures
+1 678 472 2281
MATTERS OF THE HEART THERAPEUTIC SERVICES
Client Registration & Intake Form
CLIENT IDENTIFICATION
Full Legal Name
*
Preferred Name
*
Date of Birth
*
Gender
*
Home Address
*
City
*
State
*
ZIP
*
Phone Number
*
Email Address
*
Emergency Contact Name
*
Relationship
*
Emergency Contact Phone
*
REFERRAL INFORMATION
Referral Source
*
Self
Court Ordered
Probation
DFCS
Employer
Other
Court Name (if applicable)
Case Number
*
Probation Officer
*
INSURANCE / PAYMENT
Insurance Provider
*
Policy Number
*
Self-Pay
*
Yes
No
Agreed Session Rate
*
SERVICES REQUESTED
Select Service
*
Substance Use Assessment
Individual Counseling
Family Counseling
Anger Management
Domestic Violence Intervention
Drug Court
Other
Total Amount
Credit / Debit Card
*
CLIENT ACKNOWLEDGEMENT
Services are confidential within legal limits. Payment is due at time of service.
Client Signature
*
Date
*
SUBMIT
Matters Of The Heart
Home
Therapeutic Services
Training Center
DUI School
Contact
SMS Policies and Procedures
+1 678 472 2281