ClIent Intake Form Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * D.O.B. * MM DD YYYY Gender Identity * Birth Sex * M F Marital Status * Single Married Divorced Widowed Race * Primary Language * Employeement * Where you work and what you do Cell Phone * (###) ### #### May we leave a voice message? * Yes No Would you like text reminders for upcoming appointments (counseling clients only)? * Yes No Home Phone * (###) ### #### May we leave a voice message? * Yes No Work Phone * (###) ### #### May we leave a voice message? * Yes No What is your religious affiliation? * What is your highest level of schooling? * Are you currently on probation/parole? * Yes No Please describe most recent legal issues you've had: * Include conviction, date arrest occurred, was probation/parole completed, and dates incarcerated (if applicable): Who is your parole/probation officer? * Why are you here today? * Circle all that apply. Counseling with licensed clinician Assessment (one appointment with counselor for recommendation) Anger Management Class (8 weeks to complete) Domestic Violence Offender Treatment Intervention Class (52 weeks to complete) Parenting Class (6 weeks to complete) Were you referred? * Yes No Who referred you? * EMERGENCY CONTACT INFORMATION Name * First Name Last Name Phone * (###) ### #### Relationship to you * I give consent for LSLC to speak to this person in regards to my care or services. * Please initial. This consent is valid for one year unless I revoke it. * Please initial. COUNSELING CLIENTS ONLY I understand if I miss three (3) appointments in a row or I am continually a No Show, I may be discharged from care. * Please initial. If at any time my clinician determines I am aggressive, threatening, or presenting a safety issue, he/she may terminate my services at will. * Please initial. I acknowledge that the above information is correct to the best of my knowledge. Client Signature * Please type name. Date * MM DD YYYY Life Skills Staff Staff member will sign name later. Life Skills Staff Date Staff member will date in later. Thank you!
