Intake Form for EMDR and Psychotherapy of Central Maryland LLC

EMDR and Psychotherapy
of Central Maryland, LLC

Intake Form

EMDR of Psychotherapy of Central Maryland. LLC
Intake Form

This sheet must be filled in completely.

First Name:
Last Name:
Address Street 1:
Address Street 2:
City:
Zip Code:	(5 digits)
State:
Home Phone:
Cell Phone:
Email:
Date of Birth:
Age:
Gender:
Race:
Current Medications:
Person Responsible for Payment:
Name of Spouse/Guardian:
Address:
Phone:
Referral Source:
	I understand that if I need to cancel my appointment, I must do so with 24-hour notice or there will be a $130 missed appointment fee.
Digital Signature: