Initial Contact Form
Holistic Life Counseling, LLC Ramey Wood Rascher, MA, LMHC, LPC
Client Information
Client Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
-
Area Code
Phone Number
Is this phone number
Home
Cell
Work
Other
Can a message be left at this phone number
Yes
No
Alternative Phone Number
-
Area Code
Phone Number
Is this phone number
Home
Cell
Work
Other
Can a message be left at this phone number
Yes
No
Skype Name or FaceTime number (if applicable)
Date of Birth
-
Month
-
Day
Year
Date
Age
Email
example@example.com
Occupation (if student - where and what grade / year?)
Who referred you to my practice?
Is it ok if I thank that person for referring you?
Yes
No
In case of emergency, the best person to contact is:
Name
First Name
Last Name
Relationship
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Submit
Should be Empty: