Client Intake Form-Confidential
Welcome to Renaissance Counseling Services. This form helps us prepare for your first session by understanding your mental health history, preferences, needs, and goals. Your responses are confidential and will guide us in shaping a therapeutic experience tailored to your care.
Section 1- Personal Details
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date
-
Month
-
Day
Year
Date
Appointment
Section 2 – Session Preferences
Preferred Session Type
In-person at my practice
Online via Psychology Today
Section 3-Presenting Concerns
Presenting Concerns- What brings you to Counseling?
How long have you been experiencing this?
Less than a month
1-6 Months
More than 6 months
Have you seen a Therapist before?
Yes
No
Section 4- Health and Wellbeing
Are you currently taking any medication
Yes
No
If yes, please list
Any diagnosed medical or mental health conditions? (Yes/No)
Yes
No
If yes, please specify
Consent Text
I confirm that the information I have provided is accurate to the best of my knowledge, and I consent to participate in counselling sessions.
Signature
Thank you for completing your intake form. We look forward to supporting you with clarity and care.
Submit
Submit
Continue
Continue
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