New Client Information

 
 
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New Client Intake Form
The intake form gives me some basic information about your background and therapeutic needs.
* Required
Personal Information
Name(s) *
Your answer
Address *
Your home or mailing address
Your answer
Primary Phone Number *
The best number for contacting you
Your answer
Work Phone Number
Your answer
May we call you at work?
Email Address *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Relationship Status
Choose
Single
Married
Divorced
Widowed
Other
Spouse's Name
(If married)
Your answer
Employer
Your answer
How long have you been at this job?
Your answer
Emergency Contact
Name *
Your answer
Phone Number *
Your answer
Current Concerns
Answer as many questions as apply to you.
What concern(s) brings you in today?
Your answer
How long have you been dealing with this (these) concerns?
Your answer
Please describe any details that relate to the concern(s).
Your answer
What do you hope to accomplish in counseling?
Your answer
Have you been in therapy before about the current concerns or related items? If so, with who and when?
Your answer
List any current medications.
Your answer
List any current physical symptoms such as lack of sleep, overeating, headaches, etc.
Your answer
Is there anything else the counselor should know about you?
Your answer
Referral
How did you find me?
Submit
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