Client Intake

New Client Intake Form

Please complete this secure form before your first session. Your responses are stored privately and are visible only to Allen.

This form is encrypted in transit and stored privately in the client portal. Only Allen Wagner can view your submission. This is not for emergencies — call 911 or 988 in a crisis.

Basic Information

First Name *

Last Name *

Email *

Phone

Date of Birth *

Pronouns

Street Address

City

State

ZIP

Emergency Contact

Contact Name

Relationship

Contact Phone

Clinical History

What brings you to therapy? (presenting concern)

How long have you been experiencing these concerns?

Have you been in therapy before?

Current medications

Medical conditions / physical health

Substance use (alcohol, caffeine, nicotine, other)

Psychiatric hospitalizations (if any)

Family mental health history

Allergies

Consent & Authorization

I consent to participate in psychotherapy with Allen Wagner, LMFT. *I consent to telehealth (video) sessions where applicable. *I acknowledge my information is stored privately in the client portal and handled per applicable privacy law (HIPAA). *I consent to be contacted at the email/phone above regarding scheduling.

Electronic Signature (type full name) *

Signature Date *

By typing your name above, you confirm this electronic signature is the legal equivalent of your handwritten signature.

Draw your signature

Sign here using your mouse or finger

Let's Begin.

Real support for complex lives — thoughtful, steady, and grounded in change.

Book a Session Contact

910.352.0434
allenwagnerlmft@gmail.com
51 S End Ct, Hampstead, NC 28443