Counseling Intake Form

Counseling Intake Form
INWORLD NAME(THIS IS YOUR SECONDLIFE USER NAME)
Date of Birth

MonthDayYear
Date
Marital Status
Email
example@example.com
Instagram?
Employment
Preferred Method of Contact
Medical History
Please check all the apply

Other
Do you use tobacco?
Do you use alcohol?
Caffeine use?
Have you been convicted of drug related charges?
Please explain the circumstances
Are you currently taking prescription medication?
Family history

Other
Mental Health History
Why you are seeking treatment?
What do you expect from this counselling?
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?
Average hours of sleep per night
Please describe any other experiences you have had problems with
Additional comments or concerns
Time? **THIS IS THE TIME THAT YOUR APPOINTMENT WILL BE, IN SECONDLIFE TIME[SLT] NOT REAL LIFE TIME**
Preferred Appointment Date.

MonthDayYear
Date
*Your signature below indicates that the information you have provided above is truthful.
Signature (Type your Inworld Name below for your signature.)
Should be Empty:

Medical History