Anxiety & Depression Therapy - Orange County CA - Liz Birch, LMFT
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    Intake Form - Adult
    Please complete this form prior to our first session.  All information is protected by confidentiality. 
    ** This is a Secure form.  All information sent will be encrypted.   

    If no children, write "none".

    *This person will not be contacted without a signed release from you.


    If none, write in "none". Your physician can not be contacted without a release of information signed by you.
    If none, write in "none" Your psychiatrist can not be contacted without a release of information signed by you.



    Suicide Crisis Line - 877 727 4747 serving Orange County. If you are feeling suicidal, or someone you know is thinking about suicide, call the 24-hour suicide crisis line to speak with someone who can provide assistance. Or you can phone 911 and let them know you need assistance.




    Thank you for taking the time to complete this form either in part or in its entirety.   During our first session you and I will be able to discuss more in-depth any areas of concern. 
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  • Home
  • About Me
  • Talk Therapy
  • Hypnotherapy
  • Fees, Insurance, Directions
  • Why Do You Want Therapy?
  • Blog
  • Important Forms
  • Podcasts
  • Confidentiality