Love Therapy Center, LLC - Client Intake Form
Love Therapy Center, LLC
San Francisco & San Diego
(415) 412-6615
(619) 376-5576
Client Record
First Name *
Your answer
Last Name *
Your answer
Date of Birth
Your answer
Address
Your answer
Phone (Cell) *
Your answer
OK to leave messages on Cell?
Phone (Work)
Your answer
OK to leave messages at Work?
Phone (Home)
Your answer
OK to leave messages at Home?
Email *
Your answer
OK to contact via email?
OK to contact via text?
Employer / School
Your answer
Emergency Contact Name
Your answer
Emergency Contact Phone
Your answer
Relevant Medical Conditions
history, current condition, changes in condition
Your answer
Medications
Your answer
Reason for seeking counseling today. Why now?
include prior history of counseling for mental health, alcohol, or other drug problems
Your answer
Relationship Status
check as many as apply
How long in this relationship status?
Your answer
Other Significant Relationships
check if you believe it has or had a significant affect on your life
Please provide a brief description of these Other Significant Relationships
Your answer
Sleeping Patterns
Your answer
Eating Patterns
Your answer
Drinking patterns
i.e. alcohol / coffee / soda / water
Your answer
Other chemical use patterns
i.e. cigarettes, drugs
Your answer
Additional Relevant Information or Areas of Concern
Please describe these areas of concern
Your answer
What are your goals for counseling? What are you afraid will happen if you do nothing? What is getting in the way of you achieving your goals?
Your answer
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