Journey To Healing
Client Intake Application- * Application is required before attending counseling session.
Applicant Name (Parent/Guardian) * For children 18 years or younger
Applicant Date of Birth
Children (First, Last Name, and D.O.B.) - Children under the age of 5 must attend session with caregiver.
Email *Please note: Email correspondence is not considered to be a confidential medium of communication.
I am a Bereaved....
Have you previously received any type of mental health services (psychotherapy, psychiatric services,etc.)?
Are you currently taking any prescription medication? □ Yes □ No
Have you ever been prescribed psychiatric medication? □ Yes □ No If yes, please list and provide dates:
5. Are you currently experiencing overwhelming sadness, grief or depression? □ No □ Yes
Are you currently experiencing anxiety, panics attacks or have any phobias?
On a scale of 1-10 (with 1 being poor and 10 being exceptional), how would you rate your relationship?
What do you consider to be some of your strengths?
Do you consider yourself to be spiritual or religious? □ No □ Yes If yes, describe your faith or belief
What would you like to accomplish out of your time in therapy?
Should be Empty:
Now create your own JotForm - It's free!
Create your own JotForm