• Solace Counseling Services

    ADULT INTAKE / CLIENT INFORMATION SHEET
  • If any of the questions DO NOT apply to you, Please type "N/A" in the blank fields.

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  • CASE INFORMATION (if not sentenced, or DMV case only, please enter N/A where applicable)

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  • TREATMENTS

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  • **PLEASE NOTE:

    GROUP DAYS/TIMES WILL BE DISCUSSED DURING INTAKE INTERVIEW.  WE WILL COLLABORATE WITH YOU TO DETERMINE THE GROUP/COUNSELOR THAT BEST FITS YOUR SCHEDULE AND NEEDS/REQUIREMENTS. 

  • INSURANCE INFORMATION

    If you will NOT be using insurance, please enter N/A
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  • SOLACE COUNSELING SERVICES

    DACODS AND DRS INFORMATION (for DUI clients only) Please enter N/A if you are not DUI or court-ordered.
  • ***Please note:  Colorado law requires us to collect certain information from you in order to legally report your progress toward DUI requirements, and to produce your DRS (Discharge Referral Summary) at the completion of your treatment.  You will need a DRS from us to prove your progress and/or completion to both the DMV and any judicial supervising agencies, such as probation or court.

    IF YOU ARE ENROLLING TO SATISFY COURT REQUIREMENTS FOR DUI OR DMV REQUIREMENTS FOR YOUR DRIVING PRIVILEGES, YOU MUST COMPLETE THIS SECTION.  IF THERE ARE ANY QUESTIONS LEFT UNANSWERED, IT COULD HINDER OR INTERRUPT YOUR INTAKE PROCESS AND THE ABILITY TO BEGIN SERVICES AT THIS AGENCY.  PLEASE TAKE TIME TO ANSWER EACH QUESTION IN FULL.  THANK YOU!

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