Counseling Center Intake and Screening Form

Counseling Center Intake and Screening Form - Lowcountry

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
Client's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Client's Email Address
example@example.com
Client's Insurance Provider
Client's Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Name of Referent (if referral is being made by someone other than the client)

First NameLast Name
Relationship of Referent to Client
Contact for Scheduling (if other than client) ie. Case Manager, Parent, Caregiver

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 for Scheduling (if other than client's email)
example@example.com
Has the client previously received counseling or therapy?
Is the client currently 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 services required by a state agency? If so, which agency is requiring the services?
Is this a child/youth in Foster Care?
Should be Empty:

Counseling Center Intake and Screening Form - Lowcountry