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Intake Information and Questions
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* Indicates required question
Name (First, Middle, and Last)
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Best phone number to reach you by:
*
Your answer
Is it okay for me to leave a message?
*
Yes
No
Address (Street, City, State, Zip)
*
Your answer
Email (Most communication will occur via email.)
*
Your answer
Relationship Status
*
Single
Married
Engaged
Partnered
Separated
Divorced
Widowed
Employment Status
*
Full-time
Part-time
Retired
Student
Unemployed
Occupation (Type N/A if unemployed.)
Your answer
Have you had counseling before?
*
Yes
No
How did you hear about me?
*
Friend or Family
Other Health Professional
Psychology Today
Online Search
Other:
Reason(s) for seeking counseling at this time:
*
Your answer
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