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Learning Curve Intake Form: Thank you for taking time to invest in yourself.
Background and Contact Information
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Email
*
Your email
First Name:
*
Your answer
Last Name:
*
Your answer
Spouse's First Name: (If coming as a couple, please ensure both have completed the intake form)
*
Your answer
Spouse's Last Name:
*
Your answer
How do you identify?
*
He
She
They/Them
Date of Birth:
*
MM
/
DD
/
YYYY
Address:
*
Your answer
Phone Number:
*
Your answer
Relationship Status:
*
Single
Dating
Engaged
Married
Divorced
Separated
Widowed
Anniversary Date:
MM
/
DD
/
YYYY
Emergency Contact: First and Last Name
Your answer
Emergency Contact: Phone Number
Your answer
Primary Care Physician:
Your answer
I give you consent to contact my emergency contact and primary care physician in the case of an emergency:
Yes
No
Just my emergency contact
Just my Primary Care Physician
Primary Care Physician information:
Your answer
Primary reason for coming to counseling:
*
Relationship
Anger
Depression
Anxiety
Family
Drugs or Alcohol
Self Awareness
How did you hear about Learning Curve?:
*
Google
Facebook
Psychology Today
Friend
Church
Other therapist or professional
Other
My first session is scheduled for: (Date and Time):
*
Your answer
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