Client Intake Form

Date *

MM

DD

YYYY

Time *

Hour

Minute

Second

AM PM

Name *

First Name

Last Name

Phone *

(###)

###

####

Can I leave a message?

Yes

No

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Sexual & Gender Identification

Heterosexual

Lesbian

Gay

Bisexual

Transgender

Queer

Intrasex

Asexual

In Question

Other

Marital Status:

Never Married

Domestic Partnership

Married

Separated

Divorced

Widowed

Do you have any allergies?

Yes

No

Do you smoke or use tobacco?

Yes

No

Currently No, But I have in the past

Do you own firearms in your home?

Yes

No

Do you consume alcohol?

Yes

No

Currently No, But I have in the past

Do you use any non-prescription/recreational drugs?

Yes

No

Currently No, But I have in the past

Have you ever been hospitalized in the past for mental health and/or for medical reasons?

Yes

No

Have you recently or in the past thought about suicide?

Yes

No

Have you ever attempted suicide?

Yes

No

Have you ever been, or are you presently in counseling or psychotherapy?

Yes

No

Religion & Spirituality

Do you consider yourself to be spiritual or religious?

Yes

No

By checking this box I acknowledge that I have answered these questions honestly and to the best of my ability. *

Yes, I have answered these questions honestly, and to the best of my ability.