Have an account?

Registration and Intake

*This form is an example and does not constitute legal advice. You should consult with a legal professional to create a waiver that meets your specific needs.

First name

Last name

Address

Email

Phone

If the client is under 18 years old, please share the names of the parents/guardians and phone numbers.

I give consent for my child to receive counseling services from Caring For You Counseling.

Birthday

Month

Day

Year

Primary Care Physician

Previous Mental Health Therapist Name and Email or Phone Number

Please list all of your medical conditions & preferences

Please briefly share what is bringing you in to see a therapist.

Psychiatric History

Have you ever had feelings or thoughts that you didn't want to live?

Yes

No

Do you currently feel as though you do not wish to live?

Yes

No

Have you ever engaged in self-harm?

Yes

No

Psychiatric Hospitalization?

Yes

No

If yes, when and where?

Childhood History

Briefly share about your parents (married, divorced, background, etc.)

Where did you grow up?

Please list siblings in birth order

Personal History

Highest grade completed

Short answer

Do you have children?

Yes

No

Please list their names/ages

Have you ever been arrested?

Yes

No

Please share any other information your therapist should know.

How did you hear about us?

I consent to receiving therapy either via In person or through telehealth services. I acknowledge that my sessions may be recorded. Those recordings will only be used by the therapist to create accurate notes.

Signature

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