248-399-7317
joekort@joekort.com
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Before filling out the intake form, please review my Client Contract and HIPAA Information.

>> Click here for the PDF version of the Intake Form.

Background Information

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?

Contact Information All information is kept strictly confidential.

Name

Address

Phone Numbers

eMail

May I put you on my mailing list?

Personal Information All information is kept strictly confidential.

Date of Birth

Race

Religion

Marital Status

Gender

Sexual / Romantic Orientation

Children

Employment Information All information is kept strictly confidential.

How long have you worked for this employer?

Emergency Contact Information

Your Partner’s Information Complete this section only if you will be seeing Joe for couple’s therapy.

Partner’s Name

Partner’s Address

Partner’s Phone Numbers

Partner’s eMail

May I put your partner on my mailing list?

Partner’s Date of Birth


Partner’s Race

Partner’s Religion

Partner’s Marital Status

Partner’s Gender

Partner’s Sexual / Romantic Orientation

Partner’s Children

Partner’s Employment Information All information is kept strictly confidential.

How long has your partner you worked for this employer?

Partner’s Emergency Contact Information