Intake Form

Client Demographics and Presenting Concerns

* Indicates required field

Full Name of Person Filling Out This Form *

Name(s) and Date(s) of Birth for Person(s) Receiving Therapy *

Your Relationship to Persons Receiving Therapy *

If the person receiving therapy is under the age of 18, are you their parent or legal guardian? *

Email *

Is this Email Address Confidential? *

Yes No Please do not email me anything

Phone *

Cell Phone *

OK to receive texts? *

Yes No

I prefer the therapist to contact me by: *

Home Phone Cell Phone Email Text

Mailing Address *

What type of counseling will this be? *

Counseling preference *

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

Comments *

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. *

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. *

I have read, understood and agree to the above terms and conditions.

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