• Counseling Client Intake Form

  • SECTION 1: CLIENT INFORMATION

  •  / /
    Pick a Date
  • Spirit, Soul, & Body

    This section is to be answered by the client, even if under 18 years of age
  • Family of Origin

  • Goals for Counseling

  • SECTION 1 - CONFIRM

  • SECTION 2: CLIENT AGREEMENT

    Thank you for reading and completing each section as indicated
  • Counselor Credentials

  • Client Confidentiality

  • Client Participation

  • SECTION 2 - CONFIRM

  • SECTION 3: FINANCIAL AGREEMENT

    Thank you for reading and completing each section as indicated
  • Session Fees

  • APS Temperament Profile

  • Cash-Pay Only

  • Payment Methods

  • Late Cancellations and Missed Appointments

  • Returned Check NSF Fee

  • Credit Card Authorization Form

  • CREDIT CARD AUTHORIZATION FORM

  • SECTION 3 - CONFIRM

  • Should be Empty: