Intake Forms

Patient Forms

New Patient Intake Forms

Please only complete an intake form if you have a confirmed appointment with one of our licensed therapists. If you have any questions or concerns prior to completing these forms, please contact our office at (540) 602-2545, option 1.

All client information is handled in a secure and confidential manner in compliance with the Health Insurance Portability and Accountability Act (HIPAA). If you’d like to review our Notice of Privacy Practices please contact our office to receive a copy.

Please download your providers PDF and fax the completed document to (540) 602-2542 or email to contact@revelationscounseling.org

To maintain confidentiality please close out of any windows containing Patient Health Information (PHI) upon completion of an intake form.