Lancaster LGBTQ+ Coalition Mental Health Intake
Please fill out the following information to the best of your ability
Email *
Legal name *
Preferred/Actual name (if different)
Current Address *
Gender *
Pronouns
Sexual Orientation
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Date of Birth *
Age *
Email *
Phone number *
Last four digits of social security number
 *asked for data purposes only
 *
What is your preferred availability? (In-person/online, days of the week, general times) *
Are you currently having thoughts of suicide? *
Have you ever had previous thoughts of suicide or attempted suicide in the past? *
If you answered yes, when and how long has it been since?
Any current medications?
Emergency contact *
Relationship to emergency contact *
What are your current reasons for pursing therapy at this time? *
What goals do you wish to achieve in therapy?
What supports do you currently have in your life? *
Have you been in therapy previously? Describe your experience *
Are you currently employed? If yes, where?
What current coping mechanisms do you use/ hobbies?
By clicking here I understand that the information I have provided is confidential and will be read only by the therapists at the Lancaster LGBTQ+ Coalition. And that I consent to be reached by the methods provided by said therapists for further scheduling and therapeutic reasons  *
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