Client Intake Form

Please provide the following information and answer the questions below.
Please note: the information you provide here is protected as confidential information.

 

Name of parent/guardian (if under 18 years):

GENERAL HEALTH AND MENTAL HEALTH INFORMATION

FAMILY MENTAL HISTORY

In the section below identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (father, grandmother, uncle, etc.)