Adult Intake Form
Please fill out this form before receiving counseling services.
Email address *
Which counselor are you meeting with? *
Name: *
Age: *
Date of Birth: *
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DD
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Address: *
Do you attend Cumberland Community Church? (Y/N) If you attend church but not Cumberland Community Church, where do you attend? (or write n/a) *
I am: *
Do you have any children/step children? If so, how many? *
Emergency Contact name, relationship, phone number: *
Have you ever been diagnosed by a therapist or psychiatrist? If so, what was/is your diagnosis? *
Please list any anti-depressant or anti-anxiety medications you are currently taking (or write n/a): *
Please list any major medical problems you currently have (or write n/a): *
Have you received counseling services before? *
Please describe your current reasons for seeking counseling at this time. If there is a particular event which triggered your decision, please list this event: *
What do you hope to achieve/address in counseling? *
Is there anything else you’d like the clinician to know? (or write n/a) *
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