Client Intake Questionnaire

Personal Information

Full NamePreferred NameDate of BirthEmail AddressPhone Number

Preferred Method of Contact

PhoneEmailText Message

Preferred Language

EnglishPortuguêsEspañol

What brings you to counseling at this time?Biggest current challengesHow long have these concerns been affecting you?

Have you previously participated in counseling or therapy?

YesNo

If yes, briefly describe your experienceHave you ever received a mental health diagnosis?

YesNoPrefer Not to Answer

If yes, please specify

Current stress level

LowModerateHighVery High

Current emotional well-being

ExcellentGoodFairPoor

Are you currently experiencing thoughts of harming yourself?

YesNo

Are you currently experiencing thoughts of harming others?

YesNo

If you answered "Yes" to either, please share more:

If you are in crisis, call 911 or 988 (Suicide & Crisis Lifeline) immediately. This form is not monitored 24/7.

What days and times are generally best for appointments?

I certify that the information provided above is accurate to the best of my knowledge.

Signature (type your full name)Date