CLIENT INTAKE FORM
Please provide the following information for our records. Leave blank any question you would rather not answer or would prefer to discuss with your therapist. Information you provide here is held to the same standards of confidentiality as our therapy.

This confidential information is provided to you in accordance with State and Federal laws and regulations including but not limited to applicable Welfare and Institutions Code, Civil Code, and HIPPA Privacy Standards. Duplication of this information for further disclosure is prohibited without the prior written authorization of the client/ authorized representative to who it pertains unless other permitted by law.
Name (first and last) *
Address
Phone number *
Email Address *
TREATMENT HISTORY
Are you currently receiving psychiatric services, professional counseling, or psychotherapy elsewhere?
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Have you had previous psychotherapy?
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Are you currently taking prescribed psychiatric medication (antidepressants or others)?
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If yes, please list.
Do you consider yourself to be religious?
Clear selection
If yes, what is your faith?
Have you ever experienced any of the following?
What do you consider to be your strengths?
What are the effective coping strategies that you have learned?
What are your goals for therapy? *
This confidential information is provided to you in accordance with State and Federal laws and regulations including but not limited to applicable Welfare and Institutions Code, Civil Code, and HIPPA Privacy Standards. Duplication of this information for further disclosure is prohibited without the prior written authorization of the client/ authorized representative to who it pertains unless other permitted by law.
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