LMHC Intake Form

Type of Therapy

IndividualCouplesFamily

How did you hear about us?

Center of Apostolic CounselingFriend/Family

If Other, please specify

Full Name*

First NameLast Name

Date of Birth*

Date

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Email Address*

example@example.com

Home Address*

Street Address

CityState / ProvincePostal / Zip CodeCountry

Emergency Contact Name*

First NameLast Name

Emergency Contact Relationship*

Emergency Contact Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Have you previously received mental health counseling or therapy?*

YesNo

If yes, please provide details (when, where, for what concerns):

Are you currently taking any medications?*

YesNo

If yes, please list medications and dosages:

Do you have any medical conditions or significant health issues?*

YesNo

If yes, please specify:

Which of the following symptoms are you currently experiencing? (Select all that apply)

Please describe your main concerns or reasons for seeking counseling:*

What are your goals for counseling or therapy?*

Are you currently experiencing thoughts of self-harm or suicide?*

YesNo

If yes, please provide details:

Have you ever attempted self-harm or suicide in the past?*

YesNo

Are you currently experiencing thoughts of harming others?*

YesNo

Do you use alcohol or drugs?*

YesNo

If yes, please describe frequency and type:

1. Unless there is an emergency, all the therapy sessions are private and confidential with the exception of specific exceptions described below: a. Child, elder or dependant abuse, b. Expressed threats of violence toward an ascertainable victim, c. Detailed planning or concrete signs of future suicide attempts, d. Sharing information is necessary to facilitate client care across multiple providers, e. Sharing information is necessary for the treatment, f. Requests from legal and administrative institutions. 2. With the Client's prior written consent, the Counselor may legally speak to another healthcare provider or Client's family members in emergency situations. The Client may direct the Counselor to share information with whomever the Client desires, and the Client may change his/her mind anytime and revoke the permission. 3. The Counselor is allowed to keep brief notes compiled by AI of the therapy session which shall be kept in strict confidence. 4. The Client may ask questions on what to expect during and end result of the therapy. 5. The Client may decline to proceed the therapy as to the techniques which may be conducted by the therapist. 6. The Client may cease to continue therapy anytime, without any impediment and may return to therapy anytime. 7. The therapist has the right to dismiss the Client from the course of therapy.

Client Signature*

Date of Signature*

Date

Client Intake Form

Client Information

Mental Health & Medical History

Current Symptoms

Treatment Goals

Risk Assessment

Consent & Acknowledgment