Client Intake Form

Please complete all required documentation prior to your scheduled examination. All information is confidential and handled in accordance with APA standards and privacy regulations.

Examination Type *

1. Informed Consent

I understand and agree that:

The polygraph examination is voluntary
Results will be shared with authorized parties as disclosed
The examination follows APA standards and ethical guidelines
I have the right to discontinue the examination at any time
Medical conditions or medications may affect results

Full Legal Name *

Date of Birth *

Email Address *

Phone Number *

Electronic Signature (Type Full Name) *

Date *

2. Medical & Medication Disclosure

All information is confidential and used only to ensure examination accuracy and your well-being.

Current Medications (include dosage and frequency)

Medical Conditions (physical or mental health)

Recent Illness or Substance Use (past 48 hours)

Anxiety or Mental Health Concerns Related to This Exam

3. Case Background Summary

Provide a brief summary of the matter being examined *

4. Additional Information

Preferred Contact Method

Photo ID Required: You must bring a valid government-issued photo identification to your scheduled examination. Acceptable forms include driver's license, passport, or state ID card.

By submitting this form, you acknowledge that all information provided is accurate and complete. False information may result in examination postponement or cancellation.

What to Bring to Your Examination

•Valid government-issued photo identification
•Any relevant case documentation or court orders
•List of current medications (if not already disclosed)
•Medical clearance documentation (if requested)

Questions about the intake process? Contact us at nuke2432@gmail.com