Anxiety & Depression Therapy - Orange County CA - Liz Birch, LMFT
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Intake Form - Military

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"



    Military
    Please bring a copy of your DD-214 to your first session so it can be retained in your file.


    Education

    Employment
    If not employed, state "Not Employed"

    Medical

    If you currently do not have a personal physician please indicate with "none".



    Symptoms / Behaviors

    Legal


    Thank you for taking the time to complete this form. When you click Submit a copy will be sent to me.  ~ Liz Birch, LMFT

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  • Home
  • About Me
  • Talk Therapy
  • Hypnotherapy
  • Fees, Insurance, Directions
  • Why Do You Want Therapy?
  • Blog
  • Important Forms
  • Podcasts
  • Confidentiality