[ Intake Form ]

Thank you for taking the time to complete the intake form.

Please allow yourself 30 – 45 minutes to complete. Each question allows me to know more about you so we can maximize our time together in sessions. This Information is held to the same confidentiality standards as counseling sessions.

Thank you.

Intake Form

May I leave a message?

May I send a text?

May I send you an email?

Have you had previous counseling?

Do you exercise?

Do you drink alcohol?

Have you ever tried to quit?

Have you had suicidal thoughts recently?

Have you had them in the past?

Are you currently in a relationship?

Please check if you have experienced in the last month:

Are you currently employed?

Family Mental Health History. Please check if any family members have history of:

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