Patient Intake

This intake form is to help me acquire some basic demographic about you or your child and allow me to get a better understanding of your reason for seeking services.  It is just a BRIEF screening tool and can be updated as needed during our time together.  For parents of children, fill this out as if you were answering it FOR your child. Your information can go in the emergency contact section.  Please call me at 843 494 8756 or email me at if you have any issues or concerns.


If you would like to download or open a PDF version of the form to print out and bring in a hard copy use the button below. (right click to download/click to open)

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