A Fresh Future Awaits.

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Client Intake Form

Client Information

Name

First Name

Last Name

Address

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City

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Contact Details

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How may I contact you?

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Home Phone

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Employment Information

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Personal Information

Date of Birth

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Marital Status

Important dates in your life together.

Names and ages of children.

Partner/Spouse's Name

Partner/Spouse's Date of Birth

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Expectations

What do you expect to get out of our sessions?

Tell me something about yourself that you think I should know.

Briefly share what you would like to overcome.

“Kayla helps me identify sources of my past and current struggles, provides me with educational resources, equips me with healthy coping skills, inspires more realistic expectations and boundaries, gently encourages my faith, and ultimately restores my love for the human I was created to be. I am beyond thankful for her support when I fall just as much as when I succeed.”

- Meagan A.