Counseling Center Intake and Screening Form

Counseling Center Intake and Screening Form - Upstate

Please fill out the following information to help us understand your needs and provide the best support.
Full Name of Client

First NameMiddle NameLast Name
Client's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client's Gender
Client's Ethnicity
Client's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Client's Email Address
example@example.com
Client's Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client's Insurance Provider
Name of Referent (if someone other than the client is completing the referral)

First NameLast Name
Referent's Relationship to Client
Contact for Scheduling (if other than client) ie. parent, guardian, case manager

First NameLast Name
Phone Number for Scheduling (if other than client's phone number)
Please enter a valid phone number.Format: (000) 000-0000.
Email Address for Scheduling (if other than client's email)
example@example.com
Have you (or the client) previously received counseling or therapy?
Are you (or the client) current receiving counseling or therapy?
What are the presenting concerns related to the referral for services (check all that apply):

Other
Please describe the reason for seeking counseling and any specific concerns or goals you have.
Are counseling services required by a state agency?
If DA is required by state agency -please provide due date:
Date DA is Needed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Is the client currently in Foster Care?
Should be Empty:

Counseling Center Intake and Screening Form - Upstate