FGP Intake

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Right to Receive a Good Faith Estimate of Expected Charges

Secure Intake Form

Welcome to Feeling Good Psychotherapy!

Please only complete this multi-page form if we've asked you to. Otherwise, please first complete our scheduling form.

The information that you present here will serve as a basis to get to know you as well as serve you better. Information will be kept in the strictest of professional confidence.

Your First Name *

Your Last Name *

Your Address Line 1 *

Your Address Line 2

Your City *

Your State *

Your Zip Code *

How would you like us to communicate with you? *

Phone

Please enter the same email address that you entered on our scheduling form.

Email Address *

Email Risk Acknowledgement & Use Consent *

I understand that the use of email is inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and consent to Feeling Good Psychotherapy therapists and/or office staff communicating with me by email

Please enter the same phone number that you entered on our scheduling form.

Your Phone Number * 🛈

Your Date of Birth * +

Your Gender *

Your Marital Status *

Single

Married

Separated

Divorced

Widowed

Other Other

Emergency Contact's Name *

Emergency Contact's Phone Number * 🛈

Emergency Contact's Relationship to You *

Parent / Guardian

Spouse

Partner

Friend

Other Other

Primary Physician's Name

Primary Physician's Phone Number 🛈

Psychiatrist's Name

Psychiatrist's Phone Number 🛈

FEELING GOOD PSYCHOTHERAPY LCSW PLLC
(914) 533-4950 • (212) 362-4490
feelinggoodcenter.com