Child/Teen Intake Form

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Initial intake form for Journey Into Wellness Counseling Services and Julie Wells LCSW, CP, TEP. Please complete the form to the best of your ability and submit at least 24 hours before session. If you have any questions or concerns, please contact Julie Wells at journeywellness@aol.com or 727-688-5800. If you have a mental health emergency, please contact 911 as this provider does not have crisis or 24 hr service.

Full Name

Date of Birth

YYYY

Phone number to receive messages and text reminders (including area code)

Full address (include city, state and zip code)

Social Security number

Child's age

First language spoken

Emergency Contact information (name/relationship/how to contact)

How were you referred?

Treatment Plan Goals: Please describe what brought you into treatment and what you hope to accomplish

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