Intake Form

Before your visit, it would be helpful for you to fill out this form.

Mark L.Smith, MA, LPC,LCSW 
PROFESSIONAL SERVICES, LLC 
14825 E 42nd St. S, Suite 208
Independence, MO 64055
Phone 816-353-5363
Fax 816-295-6100
www.independencecounselor.com

Name:_________________________________________________
Address: _______________________________________________
City: _____________________________________State:___________________ Zip:_______________________
Employer:_____________________________________________
Home Phone: Work Phone: _________________________________
Cell Phone: Email:______________________________________________

Please CIRCLE preferred means of contact and if ok to leave message: ______________________________
WOULD YOU LIKE A TEXT REMINER OF YOUR APPOINTMENT? ___ YES ___ NO
IS IT OK TO SEND YOU EMAIL MESSAGES? ______ TEXT MESSAGES _____
IS IT OK TO LEAVE A MESSAGE IN YOUR VOICE MAIL? ___ YES ___ NO
Date of birth: ______________________
Social Security Number:_______________________________

I authorize Mark Smith, MA, LPC, LCSW, to release/exchange information with my health insurance provider for billing
purposes.(For a full disclosure of my policies and your privacy rights please visit my Web Site, www.independencecounselor.com )

Insurance Provider: _______________________________
Address: ____________________________
City: State: Zip: _______________________
Phone: ______________________________
Member number: _________________________
Group Name or number: _____________________________
I here by voluntarily consent to mental health services which may include assessment and referral recommendations deemed necessary and advisable. I agree to provide at least 24 hours notification if I must cancel any appointments and failure to do so may result in my being charged for the session. I understand I am responsible to pay any fees not covered by my insurance provider for counseling services rendered by Mark L. Smith, MA, LPC, LCSW.

Signature Date: ________________________________________

Intake Info and release.doc   Counseling Contract