Client Intake Form

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Client Intake Form

Thank you for contacting Summit and taking an important step towards your mental health and wellbeing. Answering the following questions will help us to find a clinician for you. We will get back to you within 48 hours. The information you shared on this form will only be used for treatment and payment purposes.

Please contact our office at 410-329-1200 or email info@summitcounselinggroup.net if you are unable to complete the online questionnaire.

Email *

Name *

Date Of Birth

YYYY

Phone Number

Preferred Contact method

Call

Text

Clear selection

Gender

Cisgender Man

Cisgender Woman

Transgender Man

Transgender Woman

Non-binary

I prefer to use different language and can share more with my therapist

Clear selection

I am seeking services for

Counseling - Child & Family

Counseling - Anxiety & Stress

Counseling - Trauma

Counseling - Depression

Counseling - Marriage/Relationship

Counseling - Grief & Loss

Counseling - Anger

Counseling - ADHD

Counseling - OCD

Counseling - Other

Coaching - Mindfulness

Other:

Anything else we should know before potentially matching you with one of our clinicians?

How did you find out about Summit?

Referred by my primary doctor

Referred by other practice/clinicians

Referred by my family or friend

Referred by school counselor

Google Search

Psychology Today

Ads

Other:

Clear selection

Preferred Session Type

Traditional, in person

Telehealth

No preference

Clear selection

Submit

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