Love Counseling Center – Client Intake Form

Love Counseling Center – Client Intake Form

Dr. Frantz Lamour, LMHCLicensed Mental Health CounselorMarriage & Family Counseling Specialist📞 (561) 827-2760📧 lovecounseling@lovecounselingcenter.com
Welcome to Love Counseling Center.

Please complete this intake form before your scheduled session. This information will help us better understand your needs and provide you with the highest quality care.

All information is confidential and used only for clinical purposes.
Client Information
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
MaleFemaleNon-binaryPrefer not to sayOther
SingleMarriedDivorcedWidowedOther
Emergency Contact
Emergency Contact Name*

First NameLast Name
Relationship to Client*
Emergency Contact Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Type a Insurance Provider
Member ID
Policy Holder Name
Please upload the front and back of your insurance card. This helps us verify your benefits, including copay and coverage, before your session. If you do not have it available right now, you may upload it later. However, your insurance cannot be verified until it is received.
YesNo
Upload Front*

Upload the front file only.
Cancelof
Upload Back*

Upload the back file only.
Cancelof
Upload Your Driver License

Please upload a clear photo or scan of your driver license.
Cancelof
Mental Health History
YesNo
If yes, please provide details (provider, dates, reason for treatment):*
YesNo
If yes, please provide details:*
Medical Information
Do you have any current or past medical conditions?*
YesNo
If yes, please list all current medications (name and dosage):*
Currently under the care of a physician/provider*
MENTAL HEALTH HISTORY
YesNo
If yes, please describe:*
YesNo
Substance Use History
AlcoholTobaccoCannabisPrescription drugs (not as prescribed)Other
If yes, please specify frequency and amount:
Self-Harm or Suicidal Thoughts

Have you ever engaged in self-harming behaviors or experienced suicidal thoughts? If yes, please provide details and any relevant treatment history.
Coping Strategies

How do you typically cope with stress, difficult emotions, or challenging situations?
Family and Relationship History
Living Arrangements *
Relationship Status *
In a romantic relationship *
If yes, please describe the dynamics of the relationship:*
Communication breakdownTrust issuesEmotional distanceFinancial stressFrequent arguments/conflictParenting disagreementsLack of intimacy (emotional/physicalUnresolved Past IssuesDifferent values or goalsother (please spefify)
Psychosocial History
1. Educational Background *
Employed full-timeEmployed part-timeSelf-employedUnemployedStudentRetiredOther ( please specify)
3. Cultural or Religious Affiliations *
Relationship problemsFinancial stressWork-related stressHealth concernsFamily conflictParenting stressLegal issuesRecent loss/griefLife transitionsOther (please specify)
Please briefly describe your current stressors:*
REASONS FOR COUNSELING
Stress managementAnxietyDepression / low moodRelationship issuesCommunication problemsTrust issuesLife transitionsFamily issuesParenting challengesWork-related stressTrauma / past experiencesPersonal growthAnger managementOther (please specify)
COUNSELING GOALS
What are your primary goals for counseling? What changes would you like to see in your life or relationships?*
Family and Social History
Briefly describe your family background and current living situation:*
YesNo
Trauma History
YesNoPrefer not to answer
If yes, you may briefly describe (optional):
Additional Information

Is there any other information you would like to share that could help us better understand your needs and preferences for counseling?
Signature*
Date

MonthDayYear
Date
If you have any questions, please contact:

📞 (561) 827-2760
📧 lovecounseling@lovecounselingcenter.com

We look forward to supporting you.
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Love Counseling Center – Client Intake Form

Client Information

Emergency Contact

Please upload the front and back of your insurance card. This helps us verify your benefits, including copay and coverage, before your session. If you do not have it available right now, you may upload it later. However, your insurance cannot be verified until it is received.

Mental Health History

Medical Information

MENTAL HEALTH HISTORY

Substance Use History

Self-Harm or Suicidal Thoughts

Coping Strategies

Family and Relationship History

Psychosocial History

REASONS FOR COUNSELING

COUNSELING GOALS

Family and Social History

Trauma History

Additional Information