Please fill out this form after you have had your free "Meet & Greet" session with D'Angelo or Nura.

Intake Form

New Clients

Want to print out the form and physically mail it in?

Click here for the PDF version.

If you would like to fill it out digitally, please use the form below.

Fulcrum All-Terrain Therapeutic Services, LLC.

Mobile & Online Support

608-618-6552

Your First Name:

Your Last Name

Email Address:

Address:

Phone:

Your Relationship to Patient:

Patient Information

Patient's Full Legal Name:

Patient's Date of Birth:

Month

Day

Year

Patient's Age:

Patient's Preferred Name (please list all names - first and last - if you are seeking couples counseling):

Patient's Pronouns:

Emergency Contact Information

Emergency Contact Full Name:

Emergency Contact Phone Number:

Emergency Contact Relationship to Patient:

Health and Medical Information

Primary Care Physician:

Phone number:

Please list any medical conditions:

Please list any current medications:

Reasons for Seeking Help and Goals for Receiving Service

Briefly describe the problems that you are experiencing:

Have you sought help for these issue before? If yes, what kind of treatment did you receive?

What do you hope to be able to do or achieve as a result of treatment?

Have more questions?

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