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New Client Online Form

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  • MM slash DD slash YYYY
  • Household Members

  • NameAgeRelationship?Are you the legal guardian? 
  • Personal History

  • Medical History

  • Doctors involved in your healthcareSpecialtyFrequency seen 
  • Medications

  • Prescription MedicationDosageDr who prescribedReason for taking 
  • Non-prescription medicationDosageHow oftenReason for taking 
  • Past Hospitalizations

  • DatesReasonHospital / Facility 
  • Previous Counseling, EAP, or Chemical Dependency Services

  • Therapist / Facility NameDates SeenReasonHelpful? 
  • How May We Contact You? (please list all that are okay)

  • HomeWork 
  • HomeWorkCell 
  • I, the undersigned, hereby voluntarily request to receive clinical services from Vidisha A. Patel, Ed.D. I understand that these services may include individual, group, family and/or marital therapy. I acknowledge that no guarantees have been made to me as to the effect of therapeutic assessments, therapy, treatment or care of my condition. I further understand that before beginning any treatment procedure I will be given an explanation of the nature and purpose of such treatment and any probable risks involved. I may refuse any and all treatment at any time. I understand that the information I share with the therapist will be held in the strictest confidence with the exception of the following reasons as outlined by Florida Statutes: (1) you consent in writing (2) someone’s life or safety is seriously threatened (3) disclosure is required by law (4) you file a benefit claim and the claims payor requires information I understand that I am responsible for the payment of all services and I agree to provide payment should my insurance carrier fail to do so.

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Dr. Vidisha Patel


Dr. Vidisha Patel has a doctorate in Counseling Psychology and practices as a therapist in Sarasota, FL. She specializes in … More About Me
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