Intake Form - New Client

If you’ve decided you’d like to start therapy at Through the Fog Therapy, please fill out the following form and Agnes will reach out to you to schedule an appointment.

If you are a minor (under 18 years old), please have a parent or guardian fill out the form.

Please only fill out the following if you are ready to make an appointment with Agnes. If you still have questions, you are more than welcome to a free 15 minute consultation call! Head over here to fill out the contact form and Agnes will reach out to you.

Client's Name

First Name

Last Name

Date of Birth of the Client

YYYY

Name of person filling out form (if other than Client)

First Name

Last Name

Your relationship to client

Phone

(###)

###

####

Preferred method of communication

Phone

Both/it doesn't matter

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Who were you referred by?

What is the reason you are seeking therapy?

If you are filling out this form, you are ready to make an appointment - you will be sent intake paperwork and given instructions on how to set up an appointment.

If you are not ready to schedule, please do not submit this form, instead head to the contact page to schedule a consultation call or send us a text/email with your questions.