INTAKE / PRE-SCREENING QUESTIONNAIRE

Full Name

What brings you to counseling at this time?

Have you seen a mental health professional before? Provide details

If taking prescribed medications for mental health, please include the name and dosage

Have you ever attempted suicide?

Yes

No

Do you use recreational drugs?

Yes

No

Have you ever been hospitalized for a psychiatric issue?

Yes

No

Are you interested in telehealth or in-person therapy?

TeleHealth

In-person

Do you have any legal issues pending currently or upcoming (lawsuits/other)? Explain

If You Have A Question Or Need An Appointment