Intake Form

If you wish to download a PDF file of this form to print and complete by hand, click here.

Client Information

Financially Responsible Person

I acknowledge that I have had access to read over The Nicholls Group’s “Psychologist-Patient services Agreement,” (Found under the “Patient Forms” page at and accept responsibility for reading this document and asking any questions that I may have regarding services provided to me. I hereby certify that I have legal authority to seek requested services and consent for the identified staff member(s) at The Nicholls Group to provide psychological services to me and/or the person for whom I am a legal guardian. I have had an opportunity to ask questions about any concerns I have regarding the above.