Client Intake

Client Intake
Name

First NameLast Name
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Time Zone
Date of Birth

MonthDayYear
Date
Email
example@example.com
Primary Emergency Contact
Emergency Contact

First NameLast Name
Phone Number
State
Email
example@example.com
Secondary Emergency Contact
Name

First NameLast Name
Phone Number
State
Email
example@example.com
Care Team
Primary Therapist

First NameLast Name
Type of Therapist
Phone Number
Please enter a valid phone number.
Email
example@example.com
Intend on signing an ROI

YesNo
Notes
Additional Therapist

First NameLast Name
Type of Therapist
Phone Number
Email
example@example.com
Intend on signing an ROI

YesNo
Notes
Attorney

First NameLast Name
Phone Number
Email
example@example.com
Intend on signing an ROI

YesNo
Spiritual Director/Counselor/Pastor/Etc.

First NameLast Name
Phone Number
Type of Support
Email
example@example.com
Intend on signing an ROI

YesNo
Life Coach

First NameLast Name
Phone Number
Email
example@example.com
Intend on signing an ROI

YesNo
Sponsor

First NameLast Name
Phone Number
Email
example@example.com
Intend on signing an ROI

YesNo
Reasons for Support
What brings you here now?
What feels most urgent or overwhelming at this moment?
Are there any safety concerns (physical or emotional) I should know about?
Domains of Stability & Disruption
Select all that apply

Emotional healthMental clarity or decision makingPhysical wellness / nervous system regulationSpiritual groundingIdentity / sense of selfRelationships / social supportLegal issuesReputational issuesFinancial securityVocational or career disruptionRecovery or addiction related issuesOther
Self-reflection & Priorities
What are you hoping most to receive from this support?
Have you experienced a disruption similar to this one before? If yes, how is this different?
What are 1-2 things helping you stay afloat right now?
What do you already know helps calm or anchor you when things feel intense?
Logistics & Preferences
Tell me about your style of communication. Do you like space to just speak? Or do you like to be prompted with questions?
Are there any communication needs I should be made aware of?
Final Reflection
Any final thoughts I should be aware of before we begin?
Should be Empty:

Client Intake

Primary Emergency Contact

Secondary Emergency Contact

Care Team

Reasons for Support

Domains of Stability & Disruption

Self-reflection & Priorities

Logistics & Preferences

Final Reflection