Counseling Intake Form
Client Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sex
Male
Female
Gender Identity
Male
Female
Female-to-Male (FTM)/Transgender Male/Trans Man
Male-to-Female (MTF)/Transgender Female/Trans Woman
Genderqueer, neither exclusively male nor female
Additional gender category or other, please specify below
Choose not to disclose
More room to specify if desired (not required)
Marital Status
Please Select
Single
Married
Divorced
Widowed
Parent/Guardian Name (if client under 18)
First Name
Last Name
Relationship to Client
If the client is under 18, are there any custody orders?
*
Yes
No
If yes, please explain:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Home Phone
Format: (000) 000-0000.
Cell Phone
*
Format: (000) 000-0000.
Preferred Method of Contact
*
E-mail
Home Phone
Cell Phone
May we leave voicemails?
*
Yes
No
May we text you?
*
Yes
No
Presenting Problem
*
What is the primary reason you are seeking counseling at this time?
Insurance Information
Insurance Company Name
*
Subscriber Name
*
First Name
Last Name
Subscriber Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Subscriber Relationship to Patient
*
Subscriber/Member ID
*
Group Number
Please upload a picture of the front and back of your insurance cards here
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Availability
What office do you prefer to be seen in? Please check all that apply:
*
Oswego
Cicero
Telehealth (Phone or Video)
Please check all days you are available for counseling:
*
Monday
Tuesday
Wednesday
Thursday
Friday
What time frames are best for counseling? Please check all that apply:
*
Mornings (8 AM - 12 PM)
Early Afternoon (12 PM - 3 PM)
Late Afternoons/Evenings (3 PM or later)
Are you or anyone who will be coming in for appointments on a sex offender registry?
*
Yes
No
*Your signature below indicates that the information you have provided above is truthful.
Signature
*
Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: