Please fill out the form for my records.

Please click on the service agreement as well as the client/practitioner agreement links to review each. That’s where all the legal/HIPAA information is.

THANKS!

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Date of Birth

Martial Status or Partner?

If applicable, name of spouse or partner

Occupation

Children? Ages & Names

Emergency contact

Phone of emergency contact

(###)

###

####

Any present medical condition?

Any current medications?

Prescribed by

First Name

Last Name

Any past medications for psychological conditions?

In 6 months where would you like to be? What would you like your life to look like?

List the goals you’d like to work on in this timeframe.

How would you like to feel different than now?

Do you have a personal vision? If yes describe it below.

Do you have a bucket list or are there things you would like to have accomplished/achieved/experienced before you die? What are they?

By checking this box, I agree that I have read the Service Agreement and (if in Florida or Washington) the Practitioner-Client Agreement and agree to its terms and hereby acknowledge that I have received and have been given an opportunity to read a copy of Shakti Sutriasa, LCSW and Decide Differently, LLC’s Notice of Privacy Practices and that Shakti Sutriasa has reviewed and/or provided this H.I.P.A.A. compliant Privacy Notice to me on the date I completed this form. I, the client have been advised of this provider's procedures to protect my health information.

Yes, I agree to the Services Agreement and the Practitioner-Client Agreement