Patient Information

Today's Date

Full Name

Date of Birth

Home Phone Number

Cell Phone Number

Emergency Contact

Phone Number

Relationship of Emergency Contact

Who can we speak with on your behalf?

Relationship Status

Brief Description of the Presenting Issue/Concern

How did you hear about Tracy Riley Counseling?

Therapy can be a powerful force for change. In order for therapy to be most effective, it helps to have a clear and specific goal. You may find it difficult to express your hopes for therapy in the form of a goal, but please make an initial effort. We can discuss further as we spend more time together.

Feel free to list more than one goal, if you wish.

What else do we need to know in order to best enjoy this journey with you?

You can reach Tracy Riley Counseling and JAX Hypnosis by phone at 904-704-2527 or by email through our website’s secured, confidential contact page .