Client Intake Form

Welcome to Sunshine Through Motion’s Client Intake Form. Please take a few minutes to read through this informed consent form to understand more about Strength-Based Behavioral Support and learn more about the solutions that can address your concerns to get you back on track.

Client Name

First Name

Last Name

Parent / Guardian

If your client is your child who is underage please fill in your name here.

First Name

Last Name

Date of Birth

Please add the client's date of birth here.

MM

DD

YYYY

Phone

Please add your home, work, and/or mobile number here.

(###)

###

####

Email

Please add your personal or work email here.

Street Address

Please add your home address here.

City + Zipcode

Please add your town/city and zipcode here.

What is your area of concern?

Age of Consent

I understand that this consent is purely voluntary. I have had the opportunity to discuss any concerns about the services and treatment and by which all questions were answered accordingly and to my satisfaction. I also acknowledge that I am of legal age to check this box and submit this form to Sunshine Through Motion.

Confidentiality

We highly respect the privacy and confidentiality of each of our clients. We likewise believe that for counseling to be effective and successful, we must make our clients feel secure about the information that they disclose with us. We keep our clients' records in a secure manner, and we do not allow them to be accessed or to be shared with anyone else unless with the written consent of our client who owns the information, both clinical information and personal.

However, we would like to let you know that privacy has its limitations in law and as well as being a mandate report. Sunshine Through Motion will always keep the safety of the client and other members of the team safety in mind. We would like to inform you of the circumstances where we may share information with a 3rd party without your consent:

Acts of sexual abuse or misconduct criminal acts
Acts of abuse towards others such as neglect towards children, disabled, or the elderly
Acts that Sunshine Through Motion believes may cause harm to the client themselves or to others. Compelling legal orders by the court, but nonetheless we will inform the client immediately prior to compliance with the order

In case the client is below legal age, we may disclose information to parents or legal guardians.

Appointments

Each session takes 60 minutes or more depending on the contact that you pick. Each appointment sessions are on the reservation and by appointment. In case the client will not be able to attend the scheduled appointment, should call 24-hours prior appointment, to reschedule.

Voluntary Consent

I understand that this consent is purely voluntary. I have had the opportunity to discuss any concerns about the services and treatment and by which all questions were answered accordingly and to my satisfaction.

I understand that I can withdraw anytime from the therapy by informing my therapist. By signing below, I expressly give my consent to the treatment and support that Sunshine through Motion will have the best interest in sessions.