New Client Intake Form

Personal Information
Date

MonthDayYear
Date
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Email
example@example.com
Education Level:
Occupation:
Employed by:
How do you want me to contact you?
Spouse / Partner Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Email
example@example.com
Education Level:
Occupation:
Employed by:

Marital Status & Household Composition
Marital Status

SingleMarriedSeparatedDivorcedWidowedLiving Together
Please describe how long of the above checked items?
I.E. Married, 5 years
Number of previous marriages, Him & Her:
Names and ages of children:
Names and ages of step-children and other household members:

Financial Information
Annual household income:
Home

OwnRent

Areas of Concern
If Victim of Crime, Claim/Case#
Date of crime:

MonthDayYear
Date
Please describe the crime:
What issues/concerns causes you to seek treatment? Please describe:
When did this (these) problem(s) begin?
What has helped you cope with this problem?
What do you want to see happen as a result of coming here?
What have you tried on your own to solve your concern?

Family of Origin
Father’s name, age, living/deceased:
Your age at the time of your father’s death?
Mother’s name, age, living/deceased:
Your age at the time of your mother’s death?
Names and ages of siblings:
What is your current relationship like with your family?
Did you feel safe as a child in your own home?
Were you subjected to verbal, physical emotional, or sexual abuse? If so, please describe:
Please describe your childhood:

Other Information
Please describe your spiritual identity/orientation:
Please describe your sexual orientation:
Please describe your interests/hobbies:
Are you now or have you ever been involved in a lawsuit?
If so, please describe:
Do you have any legal problems such as DUI, public intoxication, or past convictions?
If so, please describe:
Any other information that would be helpful to know in helping you?
Thank you for taking the time to fill out this intake form.
Name

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date
All information is held confidential unless you give written permission to disclose.

24 hour or one day cancellation notice required for all future appointments scheduled.
Should be Empty: