Counseling Intake Form
Patient Name
*
First Name
Last Name
Marital Status
Please Select
Single
Married
Divorced
Widowed
Email
*
example@example.com
Cell Phone
*
Employment
*
Please Select
Employed
Unemployed
Disabled
Retired
Student
Referral
How did you hear about us?
Preferred Method of Contact
*
E-mail
Home Phone
Cell Phone
Emergency Contact Information
Name
*
First Name
Last Name
Phone Number
*
Relationship
*
Insurance Information
Name of Insurance
Please List Here
Mental Health History
Why you are seeking treatment?
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?
Yes
No
Additional comments or concerns
Submit
Should be Empty: