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*

FemaleMaleOther
Client's Phone Number*
Please enter a valid phone number.
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
Primary Phone Number of Scheduling Contact (if other than client's phone number)
Please enter a valid phone number.
Email Address of Scheduling Contact
example@example.com
Has the client previously received counseling or therapy?*

YesNo
Is the client currently receiving counseling or therapy?*

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

AnxietyDepressionTraumaBehavior ChallengesSubstance UseRelationship ConcernsGrief/LossEating DisordersSleep DisturbancesAttention/Focus ConcernsFamily ConflictDomestic ViolenceAdjustment/Transition ChallengesOther
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? *
Preferred Appointment Date and Time (this is not guaranteed)*
Should be Empty:

Counseling Center Intake and Screening Form - Lowcountry