Intake Form — WiserHumans

Before we start our work together, please take the time to read through the document below and fill out the form. This information is confidential and will not be shared with anyone else.

Please get in touch if you have any question!

Working together PDF

Name

First Name

Last Name

Date of Birth

YYYY

Pronouns (optional)

Home Address

First time in therapy?

Yes

General Doctor or Psychiatrist

First Name

Last Name

Emergency Contact

Name / email / phone

Is there anything more you would like to share?

I confirm having read and understood the Working Together PDF

Yes