Request for Counseling Intake
at Hope Spring Community
Client Details:
Client Details
*
First Name
Last Name
Name of Caretaker (if client is a minor and not requesting themselves)
Date of Birth of client
-
Month
-
Day
Year
Date
Age of client
Relationship to client
Self
Parent
Foster Parent
Caseworker
Other
Client/Caretaker Phone Number
*
Format: (000) 000-0000.
Client/Caretaker E-mail
example@example.com
In the event that we cannot reach you please provide an additional name and number for backup contact:
How did you hear about us?
*
Please Select
Friend
Court
Internet Search
What is your reason for seeking counseling support?
Type of counseling needed
Please Select
Adult (Couples Therapy)
Individual Adult
Child
Teen
Are you currently receiving counseling somewhere else? If so, where and for how long?
What are the days and times that could work for an intake?
Employment
Please Select
Unemployed
Looking for work
Disability
N/A for child client
If employed, are you working
Full Time
Part Time
What is your typical work schedule?
Submit
Should be Empty: