Counseling LA Intake Form

Name

Date of Birth

Phone

Email

In case of emergency

Current year and program

Ethnicity

Relationship status

Current living situation

Please describe your current concerns, challenges or symptoms?

Who referred you to counseling?

Have you had previous counseling (If so, please list when and with whom)?

Please list any current and or past medication within the past two years (please include dosage, if and when possible)

Please list family members with any current or previous emotional or physical health concerns/challenges

Current strengths/healthy coping

Need Help?