Client Intake Form

Referred By:                                    

 

Name                                                                                                                                                                       

First                                                                 Last                                                     Middle

DOB:                                       Age:              

 

Client Address:

 

                                                                                                                                                                                   

Street                                                                                                        City

                                                                                                                                                                                   

County                                                         State                                      Zip

 

Phone Number: (          )                                                     Emergency Phone: (    ­_     )                          

Cell Phone: (         )                                                                Message Phone: (          )                                         

Email: ___________________________________________________________________________________

Reason for seeking therapy at this time:

­­­­____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Employment

 

Employed at:                                                                                                   Phone#:                                             

 

Address:                                                                                                                                                                     

 

Family Income: ______________________________________________

 

Single _____ Married _____ Separated _____ Divorced _____ Widowed ____ Other _____________________

 

If in a relationship, partner’s name and length of relationship: ________________________________________

 

Names and ages of child(ren): ____________________________________________________________________________________________________________________________________________________________________________________________

 

Who lives in your home with you? Name, Sex, Age, Relationship

____________________________________________________________________________________________________________________________________________________________________________________________

 

Emergency Contact Name: __________________________________________

Relationship: ______________________Phone number: ______________________

Address: ______________________________________________________________________________________

 

 

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