Counseling Intake Form
Client Information
Date:________________
Legal Name: _____________________________________________________________
How you prefer to be addressed: ______________________________________________
Address: _________________________________________________City_____________
Zip Code ________________ Date of Birth _________________________
Telephone: Home _______________________ other _______________________________
Employer: _________________________________________ Phone:__________________
Your position or job title______________________________________________________
Marital Status: _________ Spouse’s Name_____________________________________
Please list the people in your family/household, their ages and their relationship to you:
Your family physician – Name and Phone Number:
_____________________________________________________________________________
How did you hear about us?
Phone book _______ Web site ________ Other advertising _____________
Dr/counselor (name) ___________________ Personal (name) ________________________
Date:________________
Legal Name: _____________________________________________________________
How you prefer to be addressed: ______________________________________________
Address: _________________________________________________City_____________
Zip Code ________________ Date of Birth _________________________
Telephone: Home _______________________ other _______________________________
Employer: _________________________________________ Phone:__________________
Your position or job title______________________________________________________
Marital Status: _________ Spouse’s Name_____________________________________
Please list the people in your family/household, their ages and their relationship to you:
Your family physician – Name and Phone Number:
_____________________________________________________________________________
How did you hear about us?
Phone book _______ Web site ________ Other advertising _____________
Dr/counselor (name) ___________________ Personal (name) ________________________
