Intake form for new clients Name * First Name Last Name Date of Birth * MM DD YYYY Phone * Country (###) ### #### Email * Address * Session Preference: In-person Online (Telehealth) How did you first hear about Grace to Grace Behavioral Health? Family / Friends Facebook / Instagram Google Ascension Choosing Therapy EAP Lyra Psychology Today Tava Therapist.com Therapy Den Zencare Others Briefly tell us why you are seeking therapy By submitting this form, you agree to be contacted by Grace to Grace Behavioral Health and receive relevant updates. We respect your privacy and will never share your information. Thank you!Your form has been submitted successfully.We’re excited to connect with you and will be in touch shortly.In the meantime, please schedule your availability for our Welcome Call.
