St. Stephen of Hungary Parish

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If you are interested in counseling or psychotherapy, please fill out the following Intake Form. Because we cannot guarantee privacy when sending information over the Internet, we ask that you mail or fax this form.

Fr. Eric T. Carpine
St. Stephen of Hungary Rectory
414 East 82 Street
New York, NY 10028-6056

Fax: 212-535-9221

Of course, you may always call Fr. Eric at 212-861-8500, ext. 111, or send him an email at ecarpine@aol.com.

Intake Form

Date:
Name:
Address:
Daytime Telephone Number:
Evening Telephone Number:

Presenting Problem: What is going on at this time and what are some things that might have led up to this situation or issue that you are dealing with?

Please check one of the following:
	Individual Therapy
	Group Therapy
	Couple Therapy

Have you been in therapy before?

Are you taking any medication relevant to therapy?

Which would your prefer?
	Daytime Appointment
	Evening Appointment

Is it okay to send a packet??
	Yes
	No

Is it okay to leave a message if not at home??
	Yes
	No

Is it okay to call you at work?
	Yes
	No

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