Counseling Client Intake Form

NOTE: * indicates an answer is required

Date

General information

Personal Information

First Name* Last Name* Age* Home Address* City* State/Province* Zip/Postal Code* Preferred Phone Number* Email* Verify Email Who gives you emotional support?*

Family Information

Current Marital Status Spouse or Significant Other Family Members*

Religious Affiliation

Your Religious Tradition Your Sect or Denomination Degree of Participation Active Moderate Inactive

Medical and Counseling Information

If you have previously seen a counselor, psychologist, or psychiatrist, please provide the following information for each therapist: the name and phone number, the date(s) of therapy, reason(s) for the therapy, how useful it was, your reason for ending, and any medications that were prescribed.

Please list all medications you are currently taking.*

Additional Information

Please describe what is troubling you most? What else might be helpful for me to know about you? How did you find out about my services?

Please fill in the blank with the following letters before selecting Submit