SLCS Intake Form
Silver Lining Counseling Services
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Name  *
Today's Date
MM
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DD
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YYYY
Age and D.O.B.
Sex
Clear selection
If Minor Adult/Guardian Relation
Street Address City, State and Zip
Phone Numbers (If couple BOTH) Ok to leave a message?
Email Address (If couple, BOTH email addresses) *
Referral Source
Family Members/ Children/ Significant Others Age Relation
Presenting Problem
History Related to Problem
Family Composition and Dynamics
Education Past and Current
Employment Past and Current
Medications Past and Current
Previous Therapy (Past Diagnosis)
Family Illness History
Eating Habits
Sleep Habits
Alcohol or Drug Use
Who provides you with support and encouragement?
Do you enjoy how you spend your day? What is your favorite thing that you do each day, and what part of your day is unpleasant?
Can you describe your specific intentions and goals or what changes you would like to make happen in your life?
Please use this space to write about anything you feel is important for me to know If you prefer not to write about it, I will be happy to hear you tell me any other information when we meet.
FINANCIAL AGREEMENT Credit Card Number on File: Dameon Clay respects your time and sets aside time to see you when you make an appointment. A session usually lasts 50 minutes and payment is due at the time of session. It is important that clients respect the therapist's time as well. Clients wishing to cancel or change an appointment must give the therapist 24-hours notice. In most cases, the therapist will be able to accommodate another client if such notice is given. To impress upon clients the importance of giving advance notice when canceling appointments, the therapist requires a credit card number and information on file. If a client no-shows or cancels at the last minute or without giving 24 hours notice so that the slot may not be taken by someone else who is waiting for therapeutic care, the credit card will be charged for the full cost ($150-$170) of the missed appointment. Once again, be warned – clients who miss appointments or cancel without 24 hours notice will be charged for a full missed appointment based on the hourly rate. Please provide credit card information here. Dameon Clay will be very respectful of this information and your rights to privacy: * *
Name On Credit Card *
Credit Card Number *
Zip Code *
Expiration Date *
Security Code # (3 numbers on back of card) *
I understand that my credit card may be billed for a missed appointment if I fail to give 24 hours notice. Full Fee $150-170 *
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