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Initial Counseling Record
Questions? Contact
talk2drbaker@gmail.com
Kathleen L. Baker, Ph. D., LMFT, LBT
* Indicates required question
Date:
MM
/
DD
/
YYYY
Name
*
Your answer
Address
*
Your answer
Phone number
*
Your answer
Email
*
Your answer
Age
*
Your answer
Sex:
*
Male
Female
Number of Dependents (including yourself):
Your answer
Marital Status:
*
Single
Married
Separated
Divorced
Widowed
Other:
Length of Marriage(s):
Your answer
Current Marriage:
Your answer
Children (Name/Age/Gender/relationship):
Your answer
Place of Employment:
Your answer
Work Address:
Your answer
Type of Counseling Sought:
*
Individual
Family
Marital
Pre-Marital
Life Coaching
Grief
Blended Family
Other:
Are there any persons who are having a positive influence on your situation?
Your answer
What do you hope to accomplish by seeking counseling?
Your answer
Are you currently under medication, or is there any medical condition you are experiencing now or during the past year? Please list medications.
Your answer
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