Individual Counseling Intake Form

Individual Counseling Intake Form

Please complete the following confidential form to help us better understand your needs and provide you with effective counseling services.
Personal Information
First Name*
Middle Initial
Last Name*
Maiden Name
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Military Service

YesNo
Race
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Apt
City*
State*
ZIP*
County
Primary Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Primary Phone Type

CellHomeWorkOther
Okay to leave message on primary phone?

YesNo
Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone Type

CellHomeWorkOther
Okay to leave message on secondary phone?

YesNo
Email
example@example.com
Okay to email?

YesNo
Emergency Contact Name*
Emergency Contact Relation*
Emergency Contact Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Student

YesNo
If yes, where?
Grade/Year
Having trouble in school?

YesNo
Highest Level of Education
Place of Employment
How long employed
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Primary Care Physician
Physician City/State
Physician Phone
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Information
Primary Insurance
Subscriber ID (including letters)
Group Number
Policy Holder Full Name
Policy Holder Date of Birth

MonthDayYear
Date
Policy Holder Relation

SelfSpouseParentOther
Secondary Insurance
Secondary Subscriber ID (including letters)
Secondary Group Number
Secondary Policy Holder Full Name
Secondary Policy Holder Date of Birth

MonthDayYear
Date
Secondary Policy Holder Relation

SelfSpouseParentOther
Medicaid ID
Consent and Agreement
Client Printed Name*
Date*

MonthDayYear
Date
Client Signature (14 & older)*
Parent/Guardian Signature (if applicable)
Parent/Guardian Printed Name (if applicable)
Date (Parent/Guardian)

MonthDayYear
Date
Witness (LWCC Staff Member) Signature
Witness Printed Name
Date (Witness)

MonthDayYear
Date
Should be Empty:

Individual Counseling Intake Form

Personal Information

Insurance Information

Consent and Agreement