Before filling out the intake form, please review my Client Contract and HIPAA Information.
>> Click here for the PDF version of the Intake Form.
What is causing you to seek services at this time?
Which therapist are you scheduled for an intake?
What type of services are you pursuing with Joe?
Were you referred to Joe Kort & Associates?
May I put you on my mailing list?
Date of Birth
Sexual / Romantic Orientation
How long have you worked for this employer?
Partner’s Phone Numbers
May I put your partner on my mailing list?
Partner’s Date of Birth
Partner’s Marital Status
Partner’s Sexual / Romantic Orientation
How long has your partner you worked for this employer?