Photograph by Abe Goodale
Photograph by Abe Goodale
Photograph by Abe Goodale
Photograph by Abe Goodale
Photograph by Abe Goodale
Photograph by Abe Goodale
Photograph by Abe Goodale
Photograph by Abe Goodale
Photograph by Abe Goodale
Photograph by Abe Goodale
Photograph by Abe Goodale
Photograph by Abe Goodale

New Client Intake Form


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PERSONAL INFORMATION



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HEALTH HISTORY









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CONSENT STATEMENTS

Please place your name or initials in the boxes below as a digital signature verifying your consent to the two statements below:

1. I respect the confidentiality of all clients; however, I regularly share my cases with my supervisor, students and professional peer groups. I use clients' initials or change the name when using a case for teaching purposes. As a client of Martha's, I give my consent for her to consult with other professionals about my case and for her to use my case for teaching purposes.



2. I understand that Martha Derbyshire is not a licensed medical practitioner. I agree to maintain a relationship with a medical doctor for health concerns that require such medical attention.


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