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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*
Date Format: MM slash DD slash YYYY
Client Name*
First Last
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
Gender
- Male
- Female
- Transgender, presents as Male
- Transgender, presents as Female
- Other
- Prefer not to say
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

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2610 W. Richwoods Blvd, Peoria, IL 61604

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