Adult Intake Questionnaire

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Client Name *

Date of Birth *

YYYY

Birth Sex *

Female

Male

Prefer not to say

Gender Identity

Address *

Phone Number *

Email Address *

I would like to be contacted via *

Phone

Both

How did you hear about us?

Emergency Contact

Name of Emergency Contact *

Relationship to Client *

Emergency Contact Phone Number *

Brief description of reason for seeking counseling *

Clinician *

Please select the email address for the clinician you will be meeting with. If you aren't sure, please refer to the welcome email you recieved and used to get to this form.

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