Client Intake Form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Would you prefer your therapy session to be -
*
Face to Face sessions
Zoom
Phone
Preferred methods of contact
*
Email
Phone call
Text
All of the above
Briefly describe your family background and history
*
What motivated you to seek therapy right now?
*
What are your goals in these sessions?
*
What do you hope to address or change through therapy?
*
How would you rate your emotional. mental well - being? (1 low - 10 high)
*
1
2
3
4
5
6
7
8
9
10
Describe your current support system? (Family, friends, community groups)
*
How do you generally manage stress or emotional discomfort?
*
Do you have any concerns or questions about the process?
*
Signature
Submit
Should be Empty: