Counseling Intake & Readiness Form

Full Name*

First NameMiddle NameLast Name

Email Address*

example@example.com

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Preferred Contact Method

Date of Birth

Date

Marital Status

Emergency Contact Name

First NameMiddle NameLast Name

Emergency Contact Phone

Please enter a valid phone number.Format: (000) 000-0000.

What brings you to counseling at this time?*

How long have you been experiencing this concern?

How intense is this concern right now?*

What have you tried so far to address it?

What emotional concerns are you currently experiencing?*

If you selected Other, please explain

How would you rate your current emotional well-being?*

Have you previously received counseling or therapy?*

YesNo

If yes, please briefly explain your previous counseling or therapy experience

Current relationship status*

Describe your primary support system

Are you currently experiencing significant life transitions?*

YesNo

If yes, please explain

Work or professional environment

Is spirituality or faith important in your life?*

YesNo

Would you like faith integrated into counseling sessions?*

YesNo

Describe your current sense of purpose or direction

How would you rate your current sleep quality?*

PoorFairGoodExcellent

Do you currently take any medications?*

YesNo

Please list your medications

Please describe your current physical health status or any medical concerns we should know about

Optional: Are there any substance use patterns or coping behaviors you would like us to be aware of?

What are you hoping to gain from counseling?*

What would progress or improvement look like for you?*

Preferred Session Format*

In-personVirtual

Preferred Days and Times*

Urgency Level*

FlexibleSoonUrgent

Your privacy matters. Information shared through this form may include personal, counseling, emotional health, spiritual, relational, or health-related information. This information will be treated with care and confidentiality. If this practice is subject to HIPAA, protected health information will be handled according to applicable privacy and security requirements. You have the right to receive or request a Notice of Privacy Practices that explains how your health information may be used and disclosed, your privacy rights, and our responsibilities. Confidentiality has legal and ethical limits. Information may need to be disclosed in certain circumstances, including but not limited to risk of harm to yourself or others, abuse or neglect, court orders, medical emergencies, or other situations required by law. Electronic communication and online form submission involve privacy considerations. We use reasonable safeguards to protect your information, but no electronic system can be guaranteed completely risk-free.

Printed Name*

First NameLast Name

I understand that confidentiality has legal and ethical limits.*

I acknowledge that I may request or receive a Notice of Privacy Practices.*

I consent to being contacted regarding counseling intake and next steps.*

I understand that this intake form does not create a counseling relationship until services are formally accepted and scheduled.*

I consent to receiving general scheduling or intake communication by email, phone, or text.

I understand that the information I provide may include sensitive personal or health-related information.*

Digital Signature*

Date*

Date

Counseling Intake & Readiness Form

Personal Information

Presenting Concern

Emotional & Mental Well-being

Relationship & Life Environment

Spiritual & Personal Alignment

Health & Lifestyle

Counseling Goals

Availability & Preferences

HIPAA, Privacy & Confidentiality Acknowledgment

Signature