Client Profile Intake Form printable pdf download

Client Profile Intake Form

Mosaic Counseling Services

Client Profile

(Please print)

_________________

Date:

Personal Information

Last Name: ______________________ First Name: ____________________ Middle Name: ______________

What is your preferred name: _____________________________

Address: _________________________________________________________ Apt.# ___________________

City: ___________________________________________ State: ________________ Zip: ________________

Date of Birth (Mo./Day/Yr.): ______________ Age: ________

Sex: Male _____ Female_____

Please list phone numbers where the counselor may contact you:

Home: (____)_________________ May we leave a message? Yes___ No___

Work: (____)_________________ May we leave a message? Yes___ No___

Cell: (____)____________________ May we leave a message and text you? Yes___ No___

Email ___________________________________ May we email you? Yes___ No___

*Please note email correspondence is not considered to be a confidential medium of communication*

Who may we contact in case of emergency (list phone number and relationship):

__________________________________________________________________________________________

Referral Source (Check all that apply):

Mosaic Website

Doctor: _________________________

Friend/Family Member

Other Website: _______________________

Employer: _______________________

Psychology Today

Insurance Company

Church: _________________________

Other: ___________________________

Mosaic Intake Form/Revised 3/15

Client Profile Intake Form