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Lifesong Client Intake Form
Client Intake
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* Indicates required question
Email
*
Your email
Today's Date
*
MM
/
DD
/
YYYY
Select Staff Member
*
Shelly Foster
Stephen Hansen
Adina Loomis
Joe Madrid
Sheri Miller
Veronica Pedersen
Bob Reece
Susan Bolint
Whitney McShane
Required
May I contact you by email
*
Yes
No
Name
*
Your answer
If minor, what is parent's name?
Your answer
DOB
*
Your answer
Age
*
Your answer
Gender
*
Female
Male
Other:
Marital Status
*
Your answer
Race
*
Your answer
SS#
*
Your answer
Drivers License #
*
Your answer
Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip
*
Your answer
Home Phone
*
Your answer
Work Phone
Your answer
Cell Phone
Your answer
May I call you at work, home, or cell?
*
Home
Work
Cell
Children & Ages
*
Your answer
Referred By
*
Your answer
Why have you come to see me today?
*
Your answer
How long have you been experiencing this?
*
Your answer
Any prior counseling experience?
*
Your answer
When?
*
Your answer
Length of counseling?
*
Your answer
For what reason?
*
Your answer
Status of your Health:
*
Excellent
Very good
Good
Fair
Poor
Physical Condition:
*
Excellent
Very good
Good
Fair
Poor
Health or physical issues I should know about:
*
Your answer
Physician's Name:
*
Your answer
Physician Address and Phone:
*
Your answer
Are you currently taking any medications? Please list:
*
Your answer
Employment:
*
Full Time
Part Time
Unemployed
Student
Employer
Your answer
Employer Address
Your answer
Sign:
*
Your answer
Date:
*
MM
/
DD
/
YYYY
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