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new client form

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Age

Occupation

Emergency Contact

Emergency Contact Phone

(###)

###

####

How did you hear about Life Forward?

Please describe the top five needs you'd like to address (from most to least important).

Hobbies and interests

Please list any hobbies and interests that you would like to share.

Thank you!

Acknowledgement of services

Name

First Name

Last Name

Acknowledgement of Services

I, the undersigned, acknowledge that I understand the following: I understand that the program of conditioning offered will include an undetermined number of sessions depending on my individual needs. I understand and agree that the major purpose of this program is for vocational or avocational self-improvement and those issues of psychogenic or functional origin are treated by psychological or medical referrals only (Business and Professions Code 2908). I also understand that there are no guarantees as to the results or progress to be made, only that the Life Forward will, to the best of its ability, endeavor to accomplish the objective of my sessions. I agree to pay the fee in full to Mary L. Smith of Life Forward at least 48 hours prior to scheduled sessions. I understand that there are no refunds for services. I agree to give 24 hours notice for all cancellations or changes of scheduled session. I understand that missing a scheduled appointment without prior cancellation or canceling with fewer than 24 hours notice I may be charged at the current full rate. I acknowledge that by typing my name below I agree to the above.

Thank you!