Intake Form | Pierce Counseling

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New Client Intake Form

HOW DID YOU HEAR ABOUT US?

FIRST NAME

LAST NAME

BEST PHONE

BEST EMAIL

PRONOUNS

CAN WE LEAVE YOU A MESSAGE?

Yes

No

WHO IS SEEKING COUNSELING?

AGE OF CHILD - IF APPLICABLE

LET'S CHECK IN ABOUT SAFETY

ARE YOU CURRENTLY TAKING MEDICATION FOR SYMPTOMS?

HAVE YOU BEEN TO COUNSELING?

Yes

No

IF SO, HOW LONG HAS IT BEEN SINCE YOUR LAST APPOINTMENT?

HOW WILL YOU PAY?

Today's Date

Current Time

Thanks for submitting!

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