Counseling Intake Form

Counseling Intake Form

Please fill out the following information to help us understand your needs and schedule your counseling session.
Full Name*

First NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Mailing Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Preferred Appointment Date and Time*

MonthDayYear
Date
Briefly describe the reason for your counseling request or any specific concerns.*
Have you previously attended counseling or therapy sessions?*

YesNo
If yes, please briefly describe your previous experience (optional).*
Signature to confirm the information provided is accurate.*

Clear
What date and time work best for you?*

MonthDayYear
Date
Hour MinutesAM/PM Option
Any other specific date and time, if the above selection is not suitable.*
Should be Empty: