Client Intake Form

Client Intake Form

Please complete this form to help us understand your needs and provide you with the best possible care.
Yes (Adult)No (Minor)

Client Identification
Full Name*

First NameLast Name
Email Address
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Birth*

MonthDayYear
Date
Age*
FemaleMaleOther
Education Completed
Referred By
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

School

Minor
Current School
School's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Previous School
Previous Schools Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Occupation and Income

Adult
Current Place of Employment
Employer's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Previous Employment
Previous Employment's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Annual Income

Before Deductions
Client's:
Mate's

Emotional Health
YesNo
If so, When?
(i.e last year, 3 years ago, 2017)
YesNo
When?
With Whom?
YesNo
Adult

(This includes experiencing combat, witnessing an accident or death, being involvedin a natural disasters--fire, flood, tornado, hurricane--or have you been the victim of abuse,sexual or otherwise, in childhood or as an adult.)
Minor

(This includes witnessing an accident or death, being involved in a natural disasters-fire, flood, tornado, hurricane--or have you been the victim of abuse, sexual or otherwise.)

Previous Marriages:

Children

Confidentiality, Cancellation, and Fees Policy: Please read and acknowledge that you have understood the policies regarding confidentiality, cancellation, and fees.*
Client Signature/Parent/Guardian Signature*
Should be Empty:

Client Identification