Counseling Client Intake Form
This information you provide will remain confidential.
Please tell us about yourself:
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1.
Preferred Name/ Pronouns
(Required.)
*
2.
Date of Birth
(Required.)
*
3.
Phone
(Required.)
*
4.
Home Address
(Required.)
*
5.
Email Address
(Required.)
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6.
Personal identifier: First three letters of the city you were born (i.e. Bakersfield is “BAK”)
(Required.)
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7.
The day of the month you were born (i.e. February 1st is “01”)
(Required.)
*
8.
The first two letters of the street you grew up on (i.e. Mohawk is “MO”)
(Required.)
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9.
The first three letters of of the first school you attended (i.e. if you went to Westfield Elementary it would be WES; if you were homeschooled you would enter HOM
(Required.)
*
10.
Age Group:
(Required.)
0-15 (children/youth)
16-25 (transition age youth)
26-59 (adult)
Ages 60+ (older adults)
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11.
Gender assigned at birth:
(Required.)
Male
Female
Intersex
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12.
Current gender identity:
(Required.)
Cisgender Male
Cisgender Female
Transgender Male
Transgender Female
Non-binary
Genderfluid
Genderqueer
Questioning or unsure of gender identity
Other gender identity, not specified
Other gender identity (please specify)
*
13.
Sexual orientation:
(Required.)
Gay or Lesbian
Heterosexual or Straight
Bisexual/Pansexual+
Questioning or unsure of sexual orientation
Queer
Asexual
Another sexual orientation
Other sexual orientation (please specify)
*
14.
Primary Language:
(Required.)
English
Spanish
Both English and Spanish
Other
Other language (please specify)
*
15.
Disabilities:
(Required.)
Vision (difficulty seeing)
Hearing, or difficulty understanding speech
Mental/Cognitive (excludes behavioral)
Mobility/Physical
Chronic Medical Illness (not limited to pain)
Other
Decline
Other Disability (please specify)
*
16.
Veteran Status:
(Required.)
Yes
No
*
17.
Race:
(Required.)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
More than one race
Other (please specify)
*
18.
Ethnicity:
(Required.)
Caribbean
Central American
Mexican/Mexican-American/Chicano
Puerto Rican
South American
African
Asian Indian/South Asian
Cambodian
Chinese
Eastern European
European
Filipino
Japanese
Korean
Middle Eastern
Vietnamese
Two or More Ethnicities
Other (please specify)
*
19.
Do you currently have health insurance? If yes, who is your insurance company?
(Required.)
*
20.
What are your present mental health symptoms? How long have you experienced these present symptoms?
(Required.)
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21.
Have you had any counseling /therapy previously? Where did you receive counseling/therapy? Who was your provider?
(Required.)
*
22.
Have you experienced any trauma in the past (sexual assault, abuse, death of a friend or relative, car accident, bullying, etc)? If you are comfortable, please explain below.
(Required.)
*
23.
What are your counseling goals?
(Required.)
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24.
Does your family have a history of mental health concerns?
(Required.)
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25.
Who are your primary social supports?
(Required.)
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26.
What are your strengths?
(Required.)
