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Intake Form
Client Demographics and Presenting Concerns
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Indicates required field
Full Name of Person Filling Out This Form
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Name(s) and Date(s) of Birth for Person(s) Receiving Therapy
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Your Relationship to Persons Receiving Therapy
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If the person receiving therapy is under the age of 18, are you their parent or legal guardian?
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Email
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Is this Email Address Confidential?
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Yes
No
Please do not email me anything
Phone
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Cell Phone
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OK to receive texts?
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Yes
No
I prefer the therapist to contact me by:
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Home Phone
Cell Phone
Email
Text
Mailing Address
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What type of counseling will this be?
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Individual Adult
Individual Adolescent
Individual Child
Family Counseling
Couples/Marriage
Parenting Consultation
Counseling preference
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Would prefer to work from a Christian perspective in counseling
Would prefer a Non-Religious or Secular approach to counseling
Would like to discuss this with you at our first meeting
Check any or all that apply to your circumstances
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Abandonment
Adult Mental Health Concerns
Anger
Anxiety
Autism
Child or Adolescent Mental Health Concerns
Chronic Stress
Child Behavior Problems
Child Academic Concerns
Childhood Physical or Sexual Abuse
Conflict with Friend or Family Member
Caregiver Stress
Court-Mandated Counseling
Coping Skills Needed
Considering Leaving your Spouse or Partner
Divorce or Separation
Depression
Family Conflict
Fear of Abandonment
Financial Stress/Debt
Grief or Loss of a Loved One
Guilt
Health Concerns
Hyperactivity
Infidelity (Cheating)
Lonliness/Lack of Social Support
Loss of a Child
Loss of a Parent
Major Life Transition
Marital Conflict
Military Life: Deployment, Living Arrangements
Mood Swings
Need Help Making a Major Life Decision
Other Addiction
Overwhelmed
Parent/Child Conflict
Parenting Concerns
Parent of a child with autism or special needs
Pre-Marital Counseling
Previous Counseling
Previous Mental Health Diagnosis
Previous Mental Health Hospitalization
Pornography Addiction
Psychotropic Medication
Recent Job Loss or Employment Concerns
Resentment/Unable to Forgive
Sexuality Concerns
Single Parent
Social Anxiety
Social Skills
Spiritual/Religious
Substance Abuse/Dependency
Trapped Feeling
Traumatic Experience
Unhealthy Relationship(s)
Comments
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By clicking this box, I attest that I understand that all information shared with Creekside Christian Counseling is kept strictly confidential by law, that I am the person listed at the top of this form, that I have submitted this information of my own free will, and that it is accurate and correct to the best of my knowledge.
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I Agree
I understand that when submitting personal information on-line, there is always a risk of a third party either intentionally or unintentionally accessing my information. Creekside Counseling ensures the security of your protected health information with industry-standard HIPAA-Compliant data security upon receipt by the counselor, but during transmission from me to the counselor and/or if I indicate a preference for the counselor to respond to my request via text or email, I understand that my information could be intercepted by a third party. By checking this box, I am indicating that I choose to accept this risk for the purposes of transmitting this form.
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I have read, understood and agree to the above terms and conditions.
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