Counseling Intake Form

Basic Information Page
What is the main problem, as you see it? What brings you here? *
What have you done about it? *
What can we do? What are your expectations in coming here? *
As you see yourself, what kind of person are you? Describe yourself. *
Is there any other information we should know? *
What is your availability? Days of the week and timeframes.
We do the majority of our counseling on Sunday evenings at 4:00, 5:00, 6:00, and 7:00. A handful of our counselors are available during the week on Monday's, Tuesday's, Wednesday's, and Thursday's. Please provide specific day(s) or time(s) that works best for you to meet with a counselor in the Date/Time Preference field below.
Date/Time Preference: *
Please indicate if there is a specific counselor you would like to see.
We will try our best to accommodate your request based on the counselors scheduling availability.
Are you a member of Harvest New Beginnings Church? *

Yes No
Please note that you'll sign the Agreement portion of this document when you come in for your first counseling session.
Please note that you'll sign the Agreement portion of this document when you come in for your first counseling session.

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Personal Data Inventory