Intake Assessment

Wolf Therapy Services, Inc.

"Helping the world one person at a time..." Intake Assessment

Please identify and describe yourself:

	Please check the service you are interested in. Individual Therapy Couples Therapy Group Therapy E-Therapy Hypnotherapy Group Hypnosis Presentations
	Identify the main goal you would like assistance with (ex. quitting smoking, depression, etc).
	Have you ever been in therapy before? Yes No
	If yes, please state what you were in therapy for.
	What is your preferred method of communication Telephone E-mail
	Please provide your contact email or phone number.
	Please identify your availability. Weekdays Weeknights (before 7pm) Weekend Days Weekend Evenings (before 7pm)

I have read the Client Bill of Rights and understand it completely?

Yes  No

Wolf Therapy Services, Inc.

(847)877-7893