Intake Form - CoachBee Lifestyles

Today's Date *//

Name *

First

Middle

Last

Address *

Address Line 1

City

State

Zip Code

Phone *

Email *

Sex *

Date of Birth *//

Age *

Driver's License *

Upload Identification *

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Front and Back

In Case of Emergency Contact *

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Last

Emergency Contact Phone # *

All payments are required and must be confirmed 48 hours prior to services rendered. All refund claims must be made requested 24 hours prior to service's rendered by email only. Please email refund request to ibpeople21consulting@gmail.com

Type of Service *

EAP Type *

In-Office/In-Person
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EAP: Referral Source *

EAP Authorization # *

Number of Sessions Authorized *

Print Name *

Signature *

Address

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Contacts

Counseling Booking Portal