Client Information Intake Form Name * First Name Last Name Phone * (###) ### #### Is this number for home/work/cell? * Home Work Cell Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY Gender Identity Education Level Name of Spouse/Partner: Length of Relationship Names, Ages, and Location of Parents/Children: Names, Ages, and Location of Siblings: Place of Employment * Job Title Hours Worked per Week * Have you participated in counseling previously? * Yes No If Yes, please elaborate where, when, and with whom: Are you currently taking any medication or supplements? Yes No If Yes, name and dose: Prescribed by: Do you have any health problems? * Yes No If Yes, please describe: Do you have any past or present legal issues? * Yes No If Yes, please describe: Why are you requesting counseling currently? * Thank you!