Intake Form

Home Intake Form

Getting Started

Please complete the form below as thoroughly as possible. The information you provide will help inform our initial session and ensure appropriate care. All responses are confidential and used solely for clinical purposes.

"*" indicates required fields

Your Name*

First Name Last Name

Address*

Street Address Address Line 2 City State ZIP Code

Relationship Status*

Single (Never Married)

Married

Separated

Divorced

Remarried

Widowed

Date of Birth*

MM slash DD slash YYYY

Phone*

Email*

Spouse/Partner

(if couples counseling)

First Name Last Name

Address

Street Address Address Line 2 City State ZIP Code

Date of Birth

MM slash DD slash YYYY

Phone

Have you participated in counseling/coaching/consultation before?*

Yes

If yes, when and with whom?*

Are you currently being treated for a medical or behavioral health condition?*

Yes

Provide any details you choose to on your conditions and treatment

Are you on medications?*

Yes

If so, what are they?*

What are you hoping to accomplish through wellness services?*

How did you hear about me?*

Please Specify*

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Phone

This field is for validation purposes and should be left unchanged.

628 Brad Street
Shippensburg, PA 17257

[email protected]

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