Stackbit - Counseling Intake Form

Select days/times for your appointment availability (please click all that apply)

I would prefer counseling to be:
If applicable, number of children and ages.
Please separate names using a comma
Is your spouse/significant other willing to come to counseling?
Medical History
Please select all the apply.

Other
Do you drink alcohol?
Do you use drugs or take any unprescribed medications?
If yes, please specify what drugs/medications and their frequency.
Have you been convicted of any alcohol or drug related charges?
If so, please explain the circumstances.
Are you currently taking any prescription medication(s)?
If yes, please specify which medications.
Self Evaluation

Please share as much as you are comfortable with.
Why are you seeking treatment?
What area(s) of your life does this impact most? (Select all that apply)

Other
How long has this been going on?
Please rate the severity of your present concerns.
Please indicate which of the following areas are currently problems for you. (Select all that apply)

Other
What do you expect from this counseling?
Have you seen a counselor, psychologist, psychiatrist, or other mental health professional before?
What was the name of the provider?

First NameLast Name
If different from the above, what was your reason for seeking help?
On average, how many hours of sleep do you get per night?
Any additional comments or concerns?
How did you hear about us?
*Your signature below indicates that the information you have provided above is truthful.
Date

MonthDayYear
Date
Signature
Please verify that you are human
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Personal Information