Counseling Pre-Intake Form
Personal Information
Client Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
/
Month
/
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Back
Next
Insurance Information
Insurance Provider
*
(e.g., Highmark Blue Cross, etc.) If none, mark n/a.
Name of Policy Holder (if different from client)
First Name
Last Name
Back
Next
If Client is a Minor
Parent/Guardian Name
First Name
Last Name
Relationship to Minor
Back
Next
Preferred Days and Times for Services
Select Best Days for Services (select all that apply)
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Select Best Times for Services (select all that apply
*
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
Submit
Should be Empty: