Intake Form for Jamie Howard, LCSW Date MM DD YYYY Name * First Name Last Name Email * Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Insurance Co. 1 , and ID # (Note policy holder's name and birthday if not the client) Insurance Co. 2 and ID # Emergency Contact 1: Name, phone number, and relationship to you. Do you have experience with EMDR or IFS? Do you have expectations, requests, preferences... for therapy? Referred from? Request sliding scale? Approx monthly income? How did you find me (web search words, friend, doctor...)? Thank you!
