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BENE THERAPY PLLC

INTAKE FORMS

After you have been connected to a Clinician from our Intake Team, please complete the Intake Form that applies to you below

ADULT INTAKE FORM (18yo+)

Please complete the required information to initiate the Intake process.  Information will be input to your Simple Practice portal.

ADULT INTAKE FORM

Please complete the Adult Intake Form if you are 18 years or older.

ADOLESCENT
INTAKE FORM

Please complete the Adolescent Intake Form if you are 13 - 17 years old.  While you can legally complete on your own, it is recommended that you include your Parent/Guardian if they will be helping with payment and insurance.

ADOLESCENT INTAKE FORM
(13 - 17yo) 

Please complete the required information to initiate the Intake process.  Information will be input to your Simple Practice portal.

YOUTH INTAKE FORM
(5 - 12yo) 

Please complete the required information to initiate the Intake process.  Information will be input to your Simple Practice portal.

YOUTH INTAKE FORM

Please complete the Youth Intake Form if your child is 5-12 years old.  Parent/Guardian must complete form but is highly encouraged to include your child in the process.

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