Counseling Intake Form

Counseling Intake Form
Patient Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Email
example@example.com
Employment
If a minor, what school?
Cell Phone
Preferred Method of Contact

E-mailCallText
Emergency Contact Information
Name

First NameLast Name
Phone Number
Relationship
Insurance Information
Insurance Carrier/Company
Subscriber Name

First NameLast Name
Subscriber Date of Birth

MonthDayYear
Date
Subscriber Relationship to Patient
Group Number
Policy Number
Mental Health History
Is there a specific provider you are wanting to see?
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?

YesNo
Therapist Name

First NameLast Name
Reason for seeking help
Average hours of sleep per night
Please explain any legal, community support, child welfare, or probation involvement. (This does not exempt you from treatment!)
Additional comments or concerns
*Your signature below indicates that the information you have provided above is truthful.
Date

MonthDayYear
Date
Signature

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Emergency Contact Information