Form

Client Information & Appointment Policy Guidelines
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about Humantality Councseling?
Have you ever received counseling or therapy before? If yes, please provide a brief description of your previous counseling experiences, including the type of therapy and its duration.
Briefly describe the reason(s) you are seeking counseling at this time:
What are your primary goals for counseling?
Health and Wellness:
Do you have any medical or mental health diagnoses? If yes, please specify:
Are you currently taking any medications? If yes, please list them and their dosages:
Family and Relationships:
Are you in a committed relationship or married? If yes, please provide a brief description of your relationship dynamics:
Do you have children or dependents? If yes, please provide their ages:
Is there any additional information you believe is important for your therapist to know before your first session?
I understand that counseling involves discussions of personal and sensitive information. I am aware of the confidentiality policies of Humantality Counseling, and I consent to the collection and use of my information for the purpose of counseling.
Signature

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Thank you for taking the time to complete this questionnaire. Your responses will help us better understand your needs and provide you with the most effective counseling support.
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Client Information & Appointment Policy Guidelines