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Intake questionnaire
La Luna Center New Client Clinical History
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* Indicates required question
Email
*
Your email
Demographics
Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Current Age
*
Your answer
Home Address (Street, City, State, Zip)
*
Your answer
Other professionals you are working with.
Individual Therapist
Your answer
Individual Therapist Phone Number
Your answer
Medical Doctor or Clinic
Your answer
Medical Doctor or Clinic Phone Number
Your answer
Other Professional
Your answer
Other Professional Phone Number
Your answer
Country of citizenship
*
Your answer
Primary Language
*
Your answer
School Information
if applicable
School Name
Your answer
Class year
Choose
Freshman
Sophomore
Junior
Senior
5th year
Graduate
N/A
Employment Information
Employer
*
Your answer
Employment Status
*
Choose
Full Time
Part Time
N/A
Emergency Contact
Who should we contact in an emergency?
Emergency Contact Name
*
Your answer
Emergency Contact Phone Number
*
Your answer
Emergency Contact Relationship to You
*
Your answer
Financially responsible person
*
Your answer
Financially responsible person phone number
*
Your answer
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