Counseling Client Intake Form
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Preferred First Name *
Preferred Last Name *
Pronouns *
Date of Birth *
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/
DD
/
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Home Address *
Home Address Zip Code *
Phone Number *
Email Address *
Gender Assigned at Birth
Clear selection
Current Gender Identity  *
Sexual Orientation *
Age Group  *
Primary Language  *
Disabilities
Veteran Status
Clear selection
Race
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Ethnicity
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Health Insurance Provider *
Present Mental Health Symptoms *
Required
Severity of Present Mental Health Symptoms *
Have you received Mental Health Services within the last six months?  *
If Yes, Where did you receive Mental Health Services from?
If Yes, Who was your Mental Health Provider?
What are your counseling goals? *
Does your family have a history of mental health concerns? *
Who  is your primary social support? *
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