Intake Form

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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 www.thenichollsgroup.com) 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.