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Tara Kesling L.C.S.W.
818-794-9303
mentalhealthwellness4u@gmail.com
Home
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Client Portal
Intake
Telemental Health Consent
Hippa
Initial Intake
Full Name
Email Address
Date Of Birth
Address
Emergency Contacts
What type of Therapy are you looking for?
Have you been in Therapy before?
What is your gender Identity
What are your goals and expectations from Therapy?
Relationship Status
Religious
Spiritual
Physical Health
Eating Habits
Sleeping Habits
Substance abuse: Drugs Alcohol please describe- what is used and frequency:
What medications are you on?
For Physical Problems
For Mental Wellness
Whose care are you under. Please list specialty with phone number, Contact will only be made only with your signed consent to exchange or gather information.
Name
Contact Number
What are some of your presenting problems and symptoms? Please describe
Please add any other information you would like the Therapist to know:
More detailed questions will be asked once we start in Therapy
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