New Client Intake Form
Malwina Andruczyk, LCSW, SIFI

When your intake form is received, Malwina will contact you to set up a 15 minute phone screening and you will be on your way to your first session.
Please provide your full name *
Your answer
Age *
Your answer
What gender pronouns do you use? *
Such as they/them/theirs, she/her/hers, he/him/his, or whatever feels most comfortable and true to you
Your answer
How do you identify your race or ethnicity?
Your answer
Email Address *
Your answer
Phone Number *
Your answer
What are some good times to reach you for a follow up call? *
Your answer
What brings you to counseling at this time? *
Is there a something specific, such as a particular event? Be as detailed as you can.
Your answer
What are your goals for counseling? *
Your answer
Have you seen a mental health professional before? *
If you have been in treatment before, when was your last mental health session?
Your answer
What do you consider your greatest strength?
Your answer
If taking prescription medication for mental health--please list here.
Your answer
Do you use recreational drugs or alcohol? *
Have you ever been hospitalized for a psychiatric issue? If so--when was your last date of hospitalization? *
Your answer
Describe your current living situation. Do you live alone, with others, with family, etc? *
Your answer
Please check any of the following you have experienced in the last 6 months. *
Required
Anything else you would like me to know? *
Your answer
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