Client Intake Form

Please complete all fields marked with a *. When not applicable, fill in “NA”

Client Intake Form

Patient First Name

Patient Last Name

Patient ID Number

Date of Birth

Patient's Email Address

Patient's Contact Phone Number

Patient's Residential Address

Address Line 1

Address Line 2

City

Province

Is the patient a minor (younger than 18 years)?

Yes

Unfortunately, I do not see minors for therapy but can recommend my colleague, Ingrid Lamprecht. She can be reached at 082-872-3915.

I acknowledge

GP's name

Contact Number

Emergency Contact Name

Contact Number

Is the patient responsible for the account?

Yes

Responsible Person's First Name

Responsible Person's Last Name

Responsible Person's ID Number

Responsible Person's Address Details

Address Line 1

Address Line 2

City

Province

Responsible Person's Email Address

Responsible Person's Contact Telephone Number

Please indicate your payment method:

Medical Aid

Private

Medical Aid Name

Membership Number

Main Member's Name & Surname

Main Member's ID Number

For minors & dependants only: Number / code of dependent on Medical Aid

Please indicate any current medication the patient is taking, and when commenced.

Prescribing professional's name and contact number/s

Referred By?