Counseling Intake Form Please enable JavaScript in your browser to complete this form.Name *FirstLastDate of BirthAddressPhone Number (Cell, work, Home)Email *Reason for seeking therapy *Prior Therapy/Counseling ExperiencesAny Hospitalizations or more intensive treatment (dates/locations)Any medications related to mental health issuesAny trauma historyAre you currently being treated by a psychiatristPlease answer questionYesNoI understand that all of the information I have provided remains confidential and protected by current laws regarding privacyName and Date *MessageSubmit
