Initial Client Intake Form | Clarity and Ease Counseling, LLC

Personal Information

First Name

Last Name

Email Address

Phone

Gender Identity:

Pronouns:

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Emergency Contact

First Name

Last Name

Relationship to You:

Phone

Presenting Concerns

What brings you to therapy at this time?

If Other, please specify:

Mental Health History

Have you seen a therapist before?YesNo

If yes, when and for how long?

Any previous mental health diagnoses?YesNo

If yes, please specify

Are you currently taking any medication for mental health?YesNo

If yes, please list:

Have you ever been hospitalized for mental health concerns?YesNo

If yes, please describe:

Medical & Wellness Background

Have you ever been hospitalized for mental health concerns?YesNo

Please explain:

Do you use substances (alcohol, cannabis, etc.)?YesNo

If yes, how often?:

Do you have a mindfulness, gratitude, spiritual, or self-care practice?YesNo

Please describe (optional):

Goals for Therapy

What would you like to gain or change through counseling?

Consent & Confidentiality

By signing below, you acknowledge that:

Date

Initial Intake Form

With Clarity, Navigating Life Becomes Easier

Contact Shawn

508-742-5194

Mon ~ Fri 9 AM to 5 PM

clarityandeasecounseling@gmail.com

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