Intake Form

Privacy Policy – Please Review

** This information is covered by the Electronic Communications Privacy Act, 18 U.S.C. Section 2510-2521 and is legally privileged. This information and any attachments hereto may contain confidential information intended only for the use of the individual or entity named below. If you are not the intended recipient(s), or the employee or agent of the intended recipient(s), you are hereby notified that any dissemination, distribution or copying of this information is strictly prohibited. If you have received this information in error, please immediately notify the sender and delete this information from your computer. The sender does not waive any privilege in the event this information was inadvertently disseminated.**

  • Contact Information

  • Note: Email correspondence or texting is not considered to be a confidential means of communication.
  • (You may opt-out at any time.)
  • (if applicable)
  • (if applicable)
  • (if applicable)
  • (if applicable)
  • If client is an adult, please complete the following information:

  • Family Information

  • If client is a child, please complete the following information.

  • Emergency Contact Information

  • Referral Source

  • Current Situation

  • (hobbies, exercise, interests, social relationships, etc.)
  • Health History

  • Counseling History

  • Substance Abuse

  • Legal History

  • (truancy, traffic tickets, juvenile offenses, etc.)
  • (criminal, divorce, custody, civil, etc.)
  • Relationships

  • Miscellaneous