Teen Intake Form (to be completed by teen)
Initial intake form for Journey Into Wellness Counseling Services and Julie Wells LCSW, CP, TEP.  Please complete the form to the best of your ability and submit at least 24 hours before session.  If you have any questions or concerns, please contact Julie Wells at journeywellness@aol.com or 727-688-5800.  If you have a mental health emergency, please contact 911 as this provider does not have crisis or 24 hr service.
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Full Name
Date of Birth
MM
/
DD
/
YYYY
Phone number to receive messages and text reminders (including area code)
Your age
Emergency Contact information (name/relationship/how to contact)
Do you want to go to counseling or is this someone else's suggestion? 
Counseling Goals: What would you like help with?
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