Donate

Home
About Us
Services
Careers
Contact
COVID-19 Related Resources

Counseling Intake Form

Counseling Intake

Please complete the following intake information below if you are interested in receiving services from our skilled therapists, and someone will reach out to you to complete the intake process.

Date*
Date Format: MM slash DD slash YYYY
Client Name*
First Last
Preferred Name
First Last
Pronouns*
- He/Him/His
- She/Her/Hers
- They/Them/Theirs
- Something Else
If the previous answer is "Something Else", what pronoun do you prefer?
Address*
Street Address Apt. City State ZIP Code
OK to send mail to this address?*
- Yes
- No
Please provide the best phone number to reach you at.*
OK to leave messages at this phone number?*
- Yes
- No
Email*
OK to send email?*
- Yes
- No
Date of Birth*
Date Format: MM slash DD slash YYYY
Age
Gender
- Male
- Female
- Non-Binary
- Gender Fluid
- Trans-male
- Trans-female
- Not comfortable sharing
Parent / Guardian Information (if the patient is a minor)*
Name
Street Address Apt City State / Province / Region ZIP / Postal Code
Parent /Guardian Phone if different
Marital Status
- Married
- Divorced
- Separated
- Single
- Widowed
Insurance Infomation*
- Insurance / EAP
- Medicaid
- None
Availability for Appointment Time**
Referral Source
Reason for Seeking Services

Sign up for our Newsletter

Email *

Home
About Us
Services
Calendar
Blog
Careers
Locations
Contact
Privacy Policy

2610 W. Richwoods Blvd, Peoria, IL 61604

Human Rights Campaign

Human Services Collaborative

Stay Connected

Copyright © 2019 The Center for Youth & Family Solutions. | GDPR Privacy Policy