Intake Form

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Intake Form

Full Name: Date of Birth : *

Gender *

Female

Male

Address

Emergency Contact Information

Name:

Relationship to Client:

Phone Number:

Insurance Provider:

Policy Number:

Group Number:

Services Requesting

Please indicate the services you are interested in (check all that apply):

Community Support Services (PINK Mentoring, Monday Men's Mentoring, Parenting Class, Financial Literacy , Afterschool)

Peer Support

Individual Therapy

Group Therapy

Specialized Therapy in LGBTQ + Community

Substance Awareness for Everyone (S.A.F.E.)

Medication Management

Other: ____________________________

Presenting Concerns

Briefly describe the main issue(s) you are seeking help for:

How long have you been experiencing this issue?

Have you previously received any mental health treatment? ☐ Yes ☐ No

If yes, please provide details (therapy, medication, hospitalization, etc.):

Mental Health History

Are you currently taking any medication for mental health? ☐ Yes ☐ No

If yes, please list:

Substance Use:

Do you use alcohol or drugs? ☐ Yes ☐ No

If yes, please specify frequency:

Do you have a support system (family, friends, etc.)? ☐ Yes ☐ No

Who can you count on for support?

Yes

Maybe

Option 4

Clear selection

Is there anything else you feel is important for us to know?

Signature

Date:

YYYY

Submit

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