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Please note that we respect your confidentiality. Your eMail information will never be given to any other organization.

 

 

Intake Form

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 Joe’s services at this time?
What type of services are you pursuing with Joe?

Couples Therapy Group Therapy Individual Therapy Coaching

Were you referred to Joe?

Yes No

Contact Information

All information is kept strictly confidential.
Name

Address

Phone Numbers

eMail

May I put you on my mailing list? yes no

Personal Information

All information is kept strictly confidential.
Date of Birth

Race

Religion

Marital Status

Gender

MaleFemale

Sexual / Romantic Orientation

Heterosexual Gay / Lesbian Bi-Attractional / Bisexual Questioning

Children

space space space Living at Home? Yes No

space space space Living at Home? Yes No

space space space Living at Home? Yes No

space space space Living at Home? Yes No

space space space Living at Home? Yes No

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

check here if the address is the same as your own.

Partner’s Phone Numbers

Partner’s eMail

May I put your partner on my mailing list? yes no

Partner’s Date of Birth

Partner’s Race

Partner’s Religion

Partner’s Marital Status

Partner’s Gender

MaleFemale

Partner’s Sexual / Romantic Orientation

Heterosexual Gay / Lesbian Bi-Attractional / Bisexual Questioning

Partner’s Children

space space space Living at Home? Yes No

space space space Living at Home? Yes No

space space space Living at Home? Yes No

space space space Living at Home? Yes No

space space space Living at Home? Yes No

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

   
 
Joe Kort MA, LMSW, ACSW
25600 Woodward Ave, Ste 218 · Royal Oak, MI 48067
Tel: (248) 399-7317
Email Address: joekort@joekort.com
Information about Workshops joekort@joekort.com
Contact Joe's assistant joekort@joekort.com

Copyright Joe Kort 2008