Counseling Intake Form

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COUNSELING INTAKE FORM
PLEASE NOTE: ALL INFORMATION WILL BE KEPT CONFIDENTIAL
Date:________________________
Birth Date:________________________
Name:_________________________________________________________________________________________________
Address:__________________________________________City/St_________________________ Zip:______________
Your Phone #’s: (Home)__________________________________, (Work)_________________________________
( C e l l ) : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ P r e f e r r e d m e t h o d o f c o n t a c t :
______________________________
Email Address:_______________________________________________________________________________________
Your Employment/Job Title/School:_______________________________________________________________
Person responsible for your bill, if different than above:
_________________________________________________________________________________________________________
Referral Source (e.g., how you found out about services)________________________________________
Is it ok to call your home & leave message: Yes_____ No_____; At your work: Yes_____ No_____
Person to contact in case of an emergency (name/phone):______________________________________
In a few words, describe your reason for seeking counseling:___________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Have you ever had counseling before? ______Yes ______No
If yes, describe and list counselor, estimated number of sessions, any psychiatric
hospitalizations:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Describe any major changes that have occurred to you or your family in the last few years
(moves, changes in number of family members, marital status, situation or income):
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

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