CLIENT INTAKE FORM

New clients should complete this form prior to their first session.

Clinician Assigned to Client

Date of First Session

PERSONAL INFORMATION

First Name *

Last Name *

Date of Birth *

Legal Sex *

Gender Identity

Pronouns

Primary Language

SSN

Address *

Address

City

State/Province

Zip/Postal

CONTACT INFORMATION

Mobile Phone Number *

Home Phone Number

Work Phone Number

Text Messaging

Email Address *

Office that you prefer?

EMERGENCY CONTACT INFORMATION (Guardian if Client is a Minor)

Contact Name *

Relationship to Client *

Contact Phone Number *

Contact Email Address

EDUCATION INFORMATION

Currently Enrolled?

Graduation Year

Highest Grade Earned

If Yes, School

OCCUPATION INFORMATION

Occupation

Employer

Work Schedule

MARITAL INFORMATION

Marital Status

Years of Marriage

Name of Significant Other

Previously Married?

Number of Times?

Lengths of Marriages

Child 1 Name

Child 1 Age

Child 2 Name

Child 2 Age

Child 3 Name

Child 3 Age

Child 4 Name

Child 4 Age

Child 5 Name

Child 5 Age

Child 6 Name

Child 6 Age

FAMILY INFORMATION

Parent's Marital Status

Years of Marriage

Age when Separated/Divorced

Remarried?

Mother

Father

Mother's Name

Year Deceased

Father's Name

Year Deceased

Sibling 1 Name

Sibling 1 Age

Sibling 2 Name

Sibling 2 Age

Sibling 3 Name

Sibling 3 Age

Sibling 4 Name

Sibling 4 Age

Sibling 5 Name

Sibling 5 Age

Sibling 6 Name

Sibling 6 Age

MEDICAL INFORMATION

In Therapy Before?

Reason

Medical Conditions & Diagnoses

Medications

Allergies

Please provide any additional information:

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