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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*
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*
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**
Preference of Modality
- In Person
- Telehealth (video,phone)
Referral Source
Reason for Seeking Services

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