Name

First Last

Email

Phone

Services

THERAPY INTAKE

Name

Date of birth

Age

Phone

Email

Is it OK to leave a message at this number?

Yes

No

Is it OK to send you an email?

Yes

No

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer:

School:

Sex/Gender

Male

Female

Transgender Male

Transgender Female

Genderqueer

Choose not to disclose

Current relationship status (please “X” one)

Single

Married

Partnered/Committed relationship

Separated

Divorced

Remarried

Widowed

Sexual Orientation

Straight/heterosexual

Lesbian/homosexual

Gay/homosexual

Bisexual

Something else

Don’t know

Choose not to disclose

Pronouns

He/him

She/her

They/them

Other: please specify

Name of Significant other:

Age:

Occupation:

Years Married:

Previous marriages:

yes

No

List

# of years married:

years of divorce:

reason for divorce:

Who currently lives in your household?

Please list age and gender of your children:

List

Gender

Age

Relationship

Are there any relationships that you are concerned about?

Abuse History:

Are you currently in an abusive relationship?

Yes

No

If “Yes”, check the types of abuse that apply to this relationship:

How often does this occur?

Daily

Weekly

other

Other

Have you had past relationships that were abusive?

Yes

No

If “Yes”, please describe:

Were you ever sexually violated/assaulted as a child (0-18 years)?

Yes

No

List

If “Yes”, how old were you?

by whom?

Relationship

Have you ever been sexually assaulted or raped as an adult?

Yes

No

List

“Yes”, when?

by whom?

Relationship

Were charges filed?

Yes

No

Did you receive counseling?

Yes

No

Therapy History:

Are you currently receiving therapy with anyone?

Yes

No

Have you ever received any type of counseling services before today?

Yes

No

When?

From whom?

For what?

Medical History:

Do you have any current medical conditions (particularly seizures, diabetes, and sickle cell)?

Please list any mental health diagnoses received from a mental health or medical professional:

What treatments have you tried for these medical and mental health diagnoses?

Have you ever been hospitalized for medical reasons other than childbirth?

Yes

No

for what reasons?

Have you ever been hospitalized for mental health reasons?

Yes

No

Is there a history of drug or alcohol usage?

Yes

No

drug

Drug/Alcohol Type

Frequency

Is there a family history of drug or alcohol usage?

Yes

No

drug

Relationship

Describe

Are you currently taking any prescription medications? Over the counter medications?

Yes

No

Medication

Dosage

Prescribing Doctor

Have you ever suffered a head injury? (Car accidents, sports, violence, etc.)

Have you ever experienced any unusual states of consciousness like hallucinations, loss of time, long periods of confusion, out of body, etc.?

Symptom History:

Name

Phone Number

Physical Address

Email Address

What symptoms/problems are you hoping to improve?

When did these symptoms/problems first become noticeable?

What have been the major negative consequences of these symptoms/problems?

Please list your three primary goals for therapy.

1.

2.

3.

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Assessments

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Schedule

Interview (1 hr)

Supervision (1 hr)

Date(Required)

Time(Required)

:

Payment

$0.00

Name

First Last

Phone

Email

Your Role (CHECK ONE):

Prosecutor

Defense Attorney

Plaintiff Attorney

Respondent Attorney

Client

Type of Case (Check One):

Divorce/Custody

Protective Order

Criminal

Other (Please specify)

Other

Court Date

Date

_____________ Not yet scheduled

Approximate time needed for consultation

:

Brief Overview of Case

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Name

First Last

Phone

Email

Your Role (CHECK ONE):

Prosecutor

Defense Attorney

Plaintiff Attorney

Respondent Attorney

Client

Type of Case (Check One):

Divorce/Custody

Protective Order

Criminal

Other (Please specify)

Other

Court Date

Date

_____________ Not yet scheduled

Approximate time needed for consultation

:

Brief Overview of Case

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Registration for General Public Course

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Select Date

October 2026

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October 8, 2026

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October 22, 2026

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October 26, 2026

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October 27, 2026

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October 28, 2026

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Time Duration

15 Minutes

Time Duration

45 Minutes

Payments

$0.00

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Book An Appointment

THERAPY INTAKE

Who currently lives in your household?

Please list age and gender of your children:

Are there any relationships that you are concerned about?

Abuse History:

Therapy History:

Medical History:

Symptom History:

Please list your three primary goals for therapy.

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Assessments

Court Date

Court Date

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October 2026

October 8, 2026

October 12, 2026

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October 21, 2026

October 22, 2026

October 26, 2026

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October 29, 2026

Time Duration

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