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MHI COVID Intake Form
Intake for Referrals
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* Indicates required question
Email
*
Your email
Date
*
MM
/
DD
/
YYYY
Client Name:
*
Your answer
Referred by Wanda McWilliams
Parent/Guardian Name (or self)
*
Your answer
Client Age
*
Your answer
Race
*
American Indian
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or other pacific Islander
White
Gender
*
Female
Male
County of Residence:
*
Your answer
Address:
*
Your answer
Zip Code
*
Your answer
Phone number
*
Your answer
Email Address:
*
Your answer
How have you been affected by the COVID pandemic?
*
Your answer
Please provide a brief description of your reason for seeking counseling
*
Your answer
Do you have insurance?
*
Yes
No
If yes, can you afford the copay for outpatient counseling services
*
Yes
No
When would you be available to attend counseling sessions (days/times)?
*
Your answer
Would you prefer:
*
Virtual
In-person
Either
Are you able to participate in virtual sessions if that is the only option:
*
Yes
No
Any other comments
*
Your answer
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