Work With Me | The Dana Template

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Client Intake Form

Please fill out the following form to help us understand your mental health needs so that we can match you with one of our mental health professionals.

First Name

Email Address

Last Name

Date of Birth

Phone

Will you be paying for services out of pocket or using insurance? *

Out of Pocket

With Insurance

If you answered, 'With Insurance' please provide your insurance provider's name

What brings you to therapy?

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

Stressed Woman

Start Your Journey Today

Give Me a Call
(929) 900-5401

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address

70-20 Austin St,

Suite 100

Forest Hills, NY, 1137

contact

Kahbryant@UYCounseling.com

Tel.(929) 900-5401

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