Intake questionnaire
La Luna Center New Client Clinical History

Email address *
Demographics
Name *
Date of Birth *
MM
/
DD
/
YYYY
Current Age *
Home Address (Street, City, State, Zip) *
Other professionals you are working with.
Individual Therapist
Individual Therapist Phone Number
Medical Doctor or Clinic
Medical Doctor or Clinic Phone Number
Other Professional
Other Professional Phone Number
Country of citizenship *
Primary Language *
School Information
if applicable
School Name
Class year
Employment Information
Employer *
Employment Status *
Emergency Contact
Who should we contact in an emergency?
Emergency Contact Name *
Emergency Contact Phone Number *
Emergency Contact Relationship to You *
Financially responsible person *
Financially responsible person phone number *
Next
Never submit passwords through Google Forms.
This form was created inside of La Luna Center, LLC. Report Abuse