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Name

Email Address

Date of Birth

Client's Name & Date of Birth (If Minor)

Legal Sex Legal SexFemaleMalePrefer Not to Say

Client's Age

Have you ever been a client at Tomorrow Begins Today? (Current clients: Do not use this form, contact the office by phone) Have you ever been a client at Tomorrow Begins Today? (Current clients: Do not use this form, contact the office by phone)YesNo

Phone

What Are Your Pronouns?

Primary Insurance Carrier

I am interested in... I am interested in... Individual Therapy Children's Therapy Couple’s Therapy

How can we help? Please be specific.

What is your availability for an appointment over the next 3 weeks?

I understand that Tomorrow Begins Today does not provide any type of classes/group therapy, substance abuse services, addiction services, court ordered services, prescription or management of medications, ADHD or Autism assessments/diagnosis, or ABA Therapy

I understand that this appointment would be an assessment to determine the client's needs and ensure that Tomorrow Begins Today is able to provide the services needed. Should the client need a higher level of care or services that Tomorrow Begins Today does not provide, the client will be referred to the appropriate service providers