INTAKE and INFORMED CONSENT
Love Therapy Center, LLC
San Francisco & San Diego
(619) 376-5576
(415) 412-6615


Below you will be able to tell your Counselor a bit more about your background. You will also find disclosures regarding: Confidentiality, Fees & Scheduling, Telephone / Video Sessions (Telehealth), and other important information regarding your Treatment.
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Email *
OK to contact via Email? *
First Name *
Last Name *
Date of Birth *
MM
/
DD
/
YYYY
Address *
Phone (Cell) *
OK to leave messages on cell? *
OK to text on cell? *
Phone (Work)
OK to leave messages at work?
Clear selection
Phone (Home)
OK to leave messages at home?
Clear selection
Employer / School
Emergency Contact Name
Emergency Contact Phone:
Relevant Medical Conditions *
history, current condition, changes in condition
Medications *
Reason for Seeking Counseling today? Why now?
include prior history of counseling for mental health, alcohol, or other drug problems
Relationship Status
check as many as apply
How long in this relationship status?
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
Sleeping Patterns
Eating Patterns
Drinking patterns
i.e. alcohol / coffee / soda / water
Other chemical use patterns
i.e. cigarettes, drugs
Additional Relevant Information or Areas of Concern
Please describe these areas of concern
What are your goals for counseling? What brings you to counseling now? What are you afraid will happen if you do nothing? What is getting in the way of you achieving your goals?
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