Intake Form | Pierce Counseling

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New Client Intake Form

HOW DID YOU HEAR ABOUT US?

Tell Us About You

First name

Last name

Cell Phone

Email

Pronouns

Who is seeking counseling?

Age of the child

Have you been to counseling before?

Yes

No

If yes, how long since your last appointment?

Why are you seeking counseling now?

How long have you be experiencing symptoms?

Has there been something that has happened or changed to create the current feelings or the symptoms?

Are you currently taking medications for symptoms. *Please note we cannot refill your presciptions

Let's check in about safety

What is your insurance?

Thanks for submitting!

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