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
Date
Client's Gender

FemaleMaleOther
Name of Parent/Guardian if client is under 18 years old

First NameLast Name
Insurance Provider
Email Address*
example@example.com
Primary Phone Number for Scheduling*
Please enter a valid phone number.
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Have you previously received counseling or therapy?*

YesNo
What are the presenting concerns related to the referral for services (check all that apply):*

AnxietyDepressionTraumaBehavior ChallengesSubstance UseRelationship ConcernsGrief/LossEating DisordersSleep DisturbancesAttention/Focus ConcernsOther
Please describe the reason for seeking counseling and any specific concerns or goals you have.*
Are counseling services required by a state agency?*
Emergency Contact Name*

First NameMiddle NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Preferred Appointment Date and Time*
Should be Empty:

Counseling Center Intake and Screening Form - Upstate