Prismatic Counseling of Georgia, LLC-                       New Client Intake
Welcome to Prismatic Counseling of Georgia, LLC! Please take a few minutes to complete this form to provide some background and information for your clinician prior to your intake session. Everything in this form is confidential and will be confirmed during your first session.
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Email *
Legal Name (for insurance billing) *
Preferred name
Date of Birth (XX/XX/XX) *
Pronouns
Address (incl. city and zip) *
Emergency Contact (name, ph. number, relationship) *
What brings you into therapy with Prismatic Counseling? *
Have you previously participated in therapy? *
Are you currently seeing a Psychiatrist or another mental health specialist?  *
Required
What medications are you currently prescribed? *
Please check off all symptoms or problems you are currently experiencing or having trouble with: *
Required
Current or past substance abuse? *
Relationship Status (check all that apply): *
Required
Who resides in your home along with you? *
How would you describe your friendships/ social circle/ romantic relationship? *
How would you describe the relationship with your parents and siblings? *
Current or past suicidal thoughts, attempts, actions, or self-harm? *
Any hospitalizations or arrests for violent or suicidal behavior? *
Any current threats of significant loss (job, relationship, custody, etc)? *
What else should your therapist know about you?
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