Name of Client
*
First Name
Last Name
Name of parent/legal guardian
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
Name of other parent/legal guardian, if needed
First Name
Last Name
Date of Birth
*
When were you born?
MM
DD
YYYY
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Preferred Contact?
*
May we text or leave detailed messages?
*
Name
*
First Name
Last Name
Phone
*
(###)
###
####
Relation to client
*
Policy holder's name
First Name
Last Name
Policy holders DOB
MM
DD
YYYY
Legal gender:
Client's relation to insured:
Self
Spouse
Child
Other
Member ID / Insurance ID
Name and phone number (if possible) of medical doctor or institution
*
Do you have any medical conditions and/or allergies?
*
Is the client currently taking any medications? If so, please include dosages, for what, and who prescribed said medications to the best of your ability.
*
Cardholder Name
*
First Name
Last Name
Type of Card
*
Visa
Mastercard
Discover
Other
If chose other, what type of card?
Please provide your card number, the expiration date, your card's security code, and also your billing zip code.
*
Your full name and age
*
Please name a few of your hobbies and interests!
*
Any favorites or dislikes?
*
Do you have a preferred name? And do parents know of this name?
Gender Identity
*
Please provide your pronouns here:
*
Why do you think you are coming to counseling? What kind of goals do you have?
*
People living in the home
Please include names, ages, and relationship to client
Have you ever been diagnosed with any mental health condition or received counseling for emotional or substance abuse concerns?
Please include which condition, treatments, and when this occurred. Was the treatment beneficial as well?
Family members who have been diagnosed or received counseling for emotional or substance abuse concerns:
*
Please include name, relationship, condition, and treatment if possible.
Is there anything that you would like your therapist to know about your family members?
*
Significant life events
*
Some examples include births, deaths, illnesses, moves, traumatic events, etcetera.
What current school is the client attending?
*
What grade is the client in?
*
How would you describe your academic functioning in school? (Grades)
*
Did the client ever receive special services in school or have an IEP or 504 (if so, who can we contact for a copy? Social Worker name, Counselor name, Teacher name, Principal name?)
*
Should we be aware of any academic problems or special needs?
*
Are you being referred to by anyone? If so, please provide name and contact information (phone and email if possible)
*
Are you suicidal with an active plan?
*
Have you been arrested or is there a court case active?
*
Is there a GAL involved in case? Please provide information:
*
What is your availability? Please specify days and times!
*
Are you open to telehealth, face to face, or both?
*
Face to face only
Telehealth only
Both
Date of intake
*
MM
DD
YYYY
