Initial Client Intake Date-Williow Grace

Willow Grace Wellness, LLC
Initial Client Intake Date
Date

MonthDayYear
Date
Name
DOB

MonthDayYear
Date
Age
Spouse/Partner's Name (if applicable)
Emergency Contact:
Contact #
Marital Status

SingleEngagedMarriedSeperatedDivorcedWidowed
How many times have you been married?
How many times divorced ?
Widowed ?
Highest level of education completed

Jr. HighGEDHigh School2yr. College4yr. CollegeGraduate DegreePh.D.
Pending legal issues?

YesNo
If yes, what?
Client Contact Information:
To best ensure privacy and confidentialty, please list acceptable methods of contact, if messages are permitted.
Cell Phone:
Work Phone:
Other Phone:
Email
example@example.com
Mailing Address
City
State
Zip
TREATMENT INFORMATION:
Referred by:
Have you participated in previous counseling or psychological services with a psychiatrist, psychologist, therapist, pastor, or lay counselor? No Yes if yes, please underline which of the type listed above.

YesNo
If Yes, please specify which type
Reason(s) for previous counseling?
Counselor's Name, Location
Counselor's Name, Location
How long ago did you receive this counseling or psychological services

6months-1yr1yr-3yr3yr-5yr5yr or more
Briefly describe what brings you to initiate counseling now?
Please check all topics that currently apply to your reason(s) for seeking counseling

DepressionPhysical AbuseEating DisorderGriefMedical/HealthSchool/EducationPregnancy LossSuicidal ThoughtsGuilt/ShameFamily IssuesSelf-EsteemAnxietyJob StressDeath of SpouseDeath of ChildMood SwingsLGBTQWorryParentingSpiritualFinancesSelf-InjuryCompatibilityPornographyAngerGamblingSexualFaithDivorceSeparationCommunicationMarriage
What are your end goals for counseling (outcome)? Briefly explain.
Should be Empty:

Willow Grace Wellness, LLC

Initial Client Intake Date

Client Contact Information:

TREATMENT INFORMATION: