Pre-Screening Form
This information will give guidance to the therapeutic process and help specify the path to reaching your counseling goals.

Responses are confidential and can only be accessed by your therapist.
**Minor Clients**
If the client is a minor, answer to the best of your observations as their parent/guardian. It is also helpful for adolescents to complete this on their own as a self assessment in addition to the parent/guardian report.
Today's Date: *
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Client First Name: *
Your answer
Client Last Name: *
Your answer
Client Date of Birth: *
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Your Name (if you are completing for a minor) and relationship to the client
Your answer
Please answer the following questions as honestly as possible. Your response is confidential and only accessed by your therapist.
Depression *
Have you recently had difficulty in any of the following areas?
Required
Anxiety *
Have you recently experienced any of the following feelings?
Required
Moodiness *
Have you recently found yourself feeling:
Required
Social *
Have you recently had troubles with others in the areas of:
Required
Relationship *
Have you noticed any of the following challenges with your significant other
Required
Alcohol or Substance Use *
Use = alcohol, illegal drugs (including Marijuana), and prescription pills
Required
Attestation *
I have answered the above questions with honesty and to the best of my knowledge.
Electronic Signature *
I understand that by agreeing to submit this form, I am hereby providing an electronic signature.
Submit
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