DAN CARE CENTER Counseling Intake Form

DAN CARE CENTER Counseling Intake Form

Counseling Request
Client's Name

First NameLast Name
Parents Name (For minors only)

First NameLast Name
Gender of Client

MaleFemale
Counseling Request
Client's Date of Birth

MonthDayYear
Date
Contact Number

Area CodePhone Number
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status

SingleMarriedDivorcedWidowed
Occupation
Do you have any of the following conditions? If yes, please select them:

CancerHypertensionHypotensionMetal ImplantsPacemaker or DefibrillatorDiabetesClaustrophobiaHeart DiseaseThyroid DisorderHysterectomyHormonal ImbalanceEpilepsy or SeizuresBlush EasilyHIV AIDSHepatitis A/B/CMigraines/HeadachesDepression/AnxietyPsoriasisRosaceaEczemaBruise EasilySpinal Cord InjuryImmune DisorderLupusKeloid ScarringBlood Clot DisorderSkin DiseaseFibromyalgiaMenopauseCirculation DisorderVaricose VeinsOther
Biological Health Concerns (Click the one you have most often, if none, click other and type n/a)

Difficulty SleepingNervousnessHeart PalpitationsIrritationInability to ConcentrateOther
Cognitive Health Concerns (Click the one you have most often, if none, click other and type n/a)

Feelings of DoomLonelinessSuicidal ideationDifficulty concentratingOther
What is your primary reason for contacting us?
Additional comments
I agree to self pay method of payment with a minimum of 6 session

YesNoMy Organization will cover
Please list any medications you are currently taking.
Terms & Conditions
I understand that my data will be strictly confidential. This center does not sell, share, or resell information. I confirm that all information in this form is true and accurate. I confirm that if I hold some important information and complications happened, the center will not be liable. I release this center and hold harmless against any claims, expenses, damages, and liabilities.
Client Signature

Clear
Signature of Parent if under the age of 18.

Clear
Date Signed

MonthDayYear
Date
Should be Empty:

DAN CARE CENTER Counseling Intake Form

Terms & Conditions