Intake form

Name *

Email address *

What type of counseling services are you seeking?

Please select at least one option.

Individual Counseling

Family Counseling

Couples Counseling

ABA Services

IIC/BA Services

Have you previously received counseling services?

If yes, please provide details about your previous counseling experience.

What are your primary goals for seeking counseling?

Please specify any specific issues you would like to address during counseling.

How did you hear about our services?

What is your preferred method of communication?

Please select at least one option.

Phone

Email

In-Person

Please provide your date of birth.

Are you currently taking any medication for mental health?

If yes, please specify the medication(s).

Do you have any allergies or medical conditions we should be aware of?

What language(s) do you prefer for counseling sessions?

Please select at least one option.

English

Spanish

What is your availability for scheduling sessions?

Additional questions or comments

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