Bethesda Counseling Services

Client Intake form

 
 
 
 
 
 
 
 
 

Insurance (not applicable for coaching or couples therapy)

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Phone
 
Phone
 
 
 
 
 
 
 

 
 
 
 
 
mm/dd/yyyy
 

Upload insurance cards if you would like your benefits pulled

 
Drop your files here