Client Intake Form

Client Intake Form [1]

SECTION 1:

Personal & Practice Information

Full Name
This field is required.
This field is required.
This field is required.
This field is required.
Psychiatrist/ Psychologist/ Licensed Clinical Social Worker (LCSW)/ Licensed Marriage and Family Therapist (LMFT)/ Certified Addiction Counselor (CAC)/ Mental Health Counselor (MHC)/ Cognitive Behavioral Therapist (CBT)/ Occupational Therapist (OT)/ Child and Adolescent Therapist/ Mindfulness-based Therapist/ Peer Support Specialist/ Rehabilitation Counselor/ Clinical Hypnotherapist/ Expressive Therapist/ School Psychologist/ Sports Psychologist/ Forensic Psychologist/ Geriatric Psychologist/ Art Therapist/ Music Therapist/ Drama Therapist/ Play Therapist/ Hypnotherapist/ Neuropsychologist/ Trauma Specialist/ LGBTQ+ Therapist/ Family Therapist / Life Coach / Reiki Practitioner / Spiritual coach and guide
This field is required.
Your Business Address
This field is required.
This field is required.
This field is required.
This field is required.
This field is required.

SECTION 2:

Online Presence & Branding

Do you already have a Google My Business profile?
If “Yes,” provide your GMB profile link.
This field is required.
Do you already have social media pages for your practice?
If “Yes,” provide links.
Preferred Branding Style: (Select All That Apply)
Preferred Colors for Your Branding (If Any)
This field is required.

SECTION 3:

Service Selection

– Google My Business Setup & Optimization – Website Design & Portfolio Creation – Social Media Marketing & Ad Campaigns – Directory Listings & SEO – Booking System Setup -Others

SECTION 4:

Additional Notes & Confirmation

Consent Agreement

This field is required.
This field is required.
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Secure Your Booking –

  • After payment, you’ll be automatically redirected to the Client Intake Form [2].  
  • Fill out the form with your service preferences.  
  • Our team will review and start working on your package immediately.
Learn more
“Thank you for choosing TheraBizSolutions! To begin your journey toward a thriving online practice, please complete the $9 booking process below. This small fee secures your spot and allows us to start preparing your services.”
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Click the button below to proceed with booking!