C L I E N T I N TA K E F O R M

Practitioner: Larry R. Wells, M.Div, MSW, CADC

Name _____________________________________
Deepa Patel Date __________________
2/13/2019 DOB 04/29:1984
________________

Are you currently seeing a counselor?  Yes  No

Are you currently seeing a physician concerning your situation?  Yes  No

Name(s) of therapist/counselor/physician(s): ______________________________ ______________________

Does your therapist/counselor/physician know you are coming here?  Yes  No

What are you hoping to accomplish through these sessions?

Gain control of mind. Feel safe, secure and confient. Be able to live without cobstant fear of
__________________________________________________________________________________________

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Losing everything. I want to be free of my mind

__________________________________________________________________________________________

__________________________________________________________________________________________

Is there other information you believe it is important for us to know?

__________________________________________________________________________________________
I was diagnosed IBS and colitis. I am recovering. There is a great fear of food in me. I want to

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be free of fear of eating

__________________________________________________________________________________________

__________________________________________________________________________________________

I understand that Neuro-Linguistic Programming is not psychotherapy nor does Larry R. Wells claim to be
a psychotherapist. I understand that N.L.P. endeavors to help clients use their own internal resources to
make wanted changes in behavior and/or attitudes. I also understand that payment at the time of service is
required and that at this time N.L.P. is not generally covered by health or any other insurance.

Client signature: _________________________________________________ Date: _____________________

02/13/2019
 Future Life Now LLC

Deepa Patel
Legal name ___________________________________________ 02/13/2019
Date _____________________________

Preferred first name Deepa Patel

___________________________________ 04/29:1984
DOB _____________________________

 Male  Female  Other Age ________ Email __________________________________________

96 Demorest Ave
Address ___________________________________________________________________________________

Avenel
City __________________________________________ NJ
State ____________ 07001
Zip code ___________________

7323973298
Home phone _________________ 732 397 3298
Work phone _________________ Mobile phone ___________________

Occupation ___________________________________ Employer __________________________________

Relationship status:  Single  Married  Divorced  Partner  Widowed  Minor

If minor, responsible party _________________________________ Relationship ______________________

In emergency, notify _____________________________________ Best phone # ______________________

Physician __________________________________ Chiropractor ___________________________________

Other practitioner(s) ________________________________________________________________________

I heard about you from:  Dr. ______________________  Other practitioner _______________________

 Friend __________________________________  Sign on the street  Poster/Flyer  Internet search

 Facebook/Twitter  Yelp  Northsider Monthly  Northside Bits and Pieces  Whole Living Journal

 Other ___________________________________________________________________ ________________

Reason for seeking services __________________________________________________________________

__________________________________________________________________________________________

Office Policies - Initial to acknowledge understanding.

PAYMENT is required at the time of service. For medical services only, upon request, a receipt will be sent
to you that may be filed with your insurance company or flexible spending account, at your own discre-
tion. _______.

CANCELLATION POLICY: 24 hour cancellation notice required. Cancellations made less than 24 hours prior
to the appointment will be charged the full session rate. Future Life Now reserves the right to waive the
cancellation fee based on special circumstances. _______

I am also agreeing to receive emails from Future Life Now for future opportunities. _______