Client Intake form Step 1

    CLIENT INFORMATION :

    Gender:

    I authorize Lovejoy Legacy Counseling and Wellness to provide the following:

    Send mail to the address listed above:

    Leave voice messages on the phone listed above:

    Leave text messages on the cell phone listed above:

    Send e-mail to the e-mail address listed above:

    Guardian Information (if client is under 18 years old):