Client Intake Form

Abigail Ellen Reiner

Licensed Professional Counselor

Licensed Chemical dependency Counselor

Full Name*

Date of Birth*

Address*

City/State/Zip*

Phone Number*

Email Address*

Message*

Emergency Contact Name

Emergency Contact Phone

Relationship to Emergency Contact

What brings you to counseling at this time?*

Have you previously been in counseling or therapy?*

Yes

No

How severe are your symptoms?*

Mild

Moderate

Severe

Current medications*

Are you under care of a physician or psychiatrist?*

Yes

No

If yes:*

Phone Number

Have you ever been hospitalized for mental health reasons?

Yes

No

If yes, please explain:

Do you currently use any of the following?

Alcohol:

Yes

No

Tobacco:

Yes

No

Recreational drugs:

Yes

No

If yes, please describe frequency:

Relationship status:

Do you have children?

Occupation / School:

Who do you live with?

Do you have support from family or friends?

Yes

No

Insurance Provider:

Member ID:

Group Number:

Policy Holder Name:

Policy Holder DOB:

What would you like to accomplish in therapy?

Client Name

Today date

Abigail Ellen Reiner

Licensed Professional Counselor

Licensed Chemical dependency Counselor

Counseling Client Intake Form

1. Personal Information

2. Reason for Seeking Counseling

3. Current Concerns

4. Medical & Mental Health History

5. Substance Use

6. Family & Social Background

7. Insurance Information

8. Goals for Counseling

9. Consent & Agreement

Contact me

Follow me