FINANCIAL OBLIGATIONS
I understand that payment is due at each session unless specific arrangements are made and noted below. I understand that missed or cancelled appointments will incur a charge unless 24 hour notice is given.

All boxes with a red asterisk must be filled in for the form to be submitted.

Thank you.

Emergency contact:

Aida Baker
Licensed Marriage Family Therapist, #51176

SAFEHAVEN PSYCHOTHERAPY 

Contact Aida

208 Providence Mine Road, Suite 122

Nevada City, CA  95959
530-263-6882
aidabaker.mft@gmail.com

CLIENT INFORMATION
New clients please complete this confidential intake form and submit it to Aida.  

If a certain question does not apply, please indicate by marking "N/A."  Thank you.