Personal Counseling Intake Form

Personal Counseling Intake Form
Please fill out this form and submit it at least 24 hours prior to our first session. All responses are kept confidential.
Your Name

First NameLast Name
Phone Number

Area CodePhone Number
E-mail
What draws you to counseling at this time?
Have you ever seen a counselor in the past? If so, please describe your past experience (when, for how long, did you find it beneficial, etc.).
What are your current ways of moving through stress?
Please list any chronic aches, pains, or health conditions that you deal with on a daily basis.
Please list any accidents or surgeries you have had.
Please list any current medications you are taking.
Is there anything else about yourself that you feel is important for me to know?
Should be Empty: