Counseling Intake Form
Name
Address
Marital Status
Please Select
Single
Married
Divorced
Widowed
Phone
Format: (000) 000-0000.
Are you currently taking prescription medication?
Yes
No
Why you are seeking treatment?
What do you expect from this counselling?
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?
Yes
No
Reason for seeking help
Average hours of sleep per night
Please describe any other experiences you have had problems with
Additional comments or concerns
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred Contact Method: Please specify how you would like us to reach out to you.
*
Submit
Should be Empty: