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

  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Gender*
  • Marital Status*

  • Emergency Contact

  • Format: (000) 000-0000.

  • 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.

  • Will you be using insurance for your sessions? Insurance must be verified before your first session.
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  • Upload File
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  • Upload a File
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    Choose a file
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  • Mental Health History

  • Have you previously seen a counselor, therapist, or psychiatrist?*
  • Have you ever been hospitalized for mental health reasons?*

  • Medical Information

  • Are you currently taking any medications?*

  • MENTAL HEALTH HISTORY

  • Have you had any thoughts of suicide or self-harm recently?*
  • Have you ever been diagnosed with a mental health condition?*

  • Substance Use History

  • Do you use any of the following substances?

  • 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

  • BIGGEST CHALLENGE: What is the biggest challenge in your relationship right now?*

  • Psychosocial History

  • 2. Employment Status*
  • 4. Current Stressors*

  • REASONS FOR COUNSELING

  • What are your reasons for seeking counseling (Select all that apply)*

  • COUNSELING GOALS 

  • Family and Social History

  • Do you have a support system (friends, family, community)?*

  • Trauma History

  • Have you experienced any traumatic events?*

  • Additional Information

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

  • If you have any questions, please contact:

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

    We look forward to supporting you.

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