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Randall R. Lyle, Ph.D., BCN

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Randall R. Lyle, Ph.D., BCN

Home
About Me
Services
Costs
Contact
- Online Intake Form

Online Intake Form

Randall R. Lyle, Ph.D., BCN
700 16th St NE Suite 206,
Cedar Rapids, IA 52402,
United States
+1 (319) 261-2291 Office

Your information is secured by SSL encryption and password protection

General Information

First Name *

Middle Name

Last Name *

Gender *FemaleMale

Today's Date

Date of Birth *

Age *

Contact Information

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country *

Home Phone

Cell Phone

Email Address *

Ok to send email? *YesNo

Employer Information

Employer

Occupation

Bussiness Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Bussiness Phone

Social security #

Partner/ Spouse/ Parent Information

Relational Status *SingleMarriedCommitted RelationshipSeparatedDivorcedWidowed

Number of persons other than yourself living in your household?

Adults: *

Children: *

First Name:

Middle Name

Last Name

Date of Birth

Age

Employeer

Occupation

Bussiness Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Bussiness Phone

Children

Children (minor and adult)

Name

GenderFemaleMale

Age

Descriptive Comment

Other

Have you experienced any major changes or events in your life during the past year? *YesNo

Have you lost a friend, family member or other significant person during the past year? *YesNo

Are you presently seeing another counselor? *YesNo

Who? *

Have you had previous counseling or psychotherapy? *YesNo

Where? *

What brings you to therapy? *

Physician

Physician's Phone

Are there any health conditions I should be aware of? *YesNo

Please describe *

Are you currently taking any medications? *YesNo

Please list and give the reason *

How important is spirituality to you in addressing the concerns that brought you to counseling? *

Are you active in a church or other spiritual community? *YesNo

Which? *

Referral

Referring Individual:

Street Address

City

State/Province

ZIP / Postal Code

Dr. Lyle wishes to acknowledge and thank members of the professional community for their trust in referring persons to him for counseling. Your signature below gives him permission to make such contact by phone or letter.

CANCELLATION AND RETURNED CHECK POLICIES

Dr. Lyle charges for sessions canceled with less than 24 hours notice.

There will be a $25 charge for each returned check or “do not honor” credit card payment.

I have read and understand these policies.

Your Signature: *

Consent *

Yes, I agree with the privacy policy and terms and conditions. By checking this box you are signing this document and your computer's IP address will be logged.

+1 (319) 261-2291

rlyle@randallrlylephd.com

700 16th St NE Suite 206, Cedar Rapids, IA 52402, United States

Copyright © 2024 Randall R. Lyle, Ph.D., BCN

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