Client Intake Form

Assisting you is my top priority.
Truly, understanding you and your life situation is paramount to our time together.

Intake Form Overview

Please read carefully before selecting the best option

A client intake form is one way I can initially learn about you and your life process. Client intake forms are 100% confidential. Sending me a completed form before our first session gives me a chance to really ground with your life situation before our first scheduled meeting.

There’s two versions of the client intake form – Condensed or Thorough – and each one can be either Filled out Online, or Downloaded and Printed (see links below).

If you are needing assistance and a listening ear around just one particular situation, the CONDENSED client intake form might just be just right for you.

At the same time though, it is important to note that even seemingly isolated situations are informed by larger life processes. If you think this is the case or have more going on then just a single situation, I recommend filling out the second and more THOROUGH intake form. Do not to feel obligated to fill out everything on the long form. However, the more you do the more I will have an understanding of you and your life before our first session.

OPTION 1) Fill out either ONLINE FORM below for best results. Condensed form is first. SCROLL DOWN PAGE for the Long Version.

OPTION 2) DOWNLOAD either form, and e-mail file to: contact@the-listener.com.

OPTION 3) PRINT either form, fill it out and mail it to: P.O. Box 4558, Arcata, CA 95518.

 

CONDENSED (SHORT) FORM:

Scroll Down page to fill out Online,
– OR –
Click button below to download PDF or DOCX file.

THOROUGH (LONG) FORM:

Scroll Far Down page (past Condensed Form) to fill out Online,
– OR –
Click button below to download PDF or DOCX file.

CONDENSED FORM — Please Fill-in as much as you can.

OK to Phone?

OK to Phone?

OK to Phone?

Personal or Relational Concerns

LONG FORM — Please Fill-in as much as you can.

OK to Phone?

OK to Phone?

OK to Phone?

Do you have children? If yes provide information below:

Choose One:

Choose One:

Choose One:

Are you Adopted?

Were you affiliated with any church / religion growing up?

Are you currently affiliated or attending a church/religion now?

Do you have any significant health/medical issues?

Have you ever had a trauma to head, unconsciousness, or seizures?

Counseling History: Have you attended counseling previously?

Are you currently in therapy or counseling with anyone?

Have you ever been hospitalized for any mental health reasons?

Are you currently taking any psychotropic medications?er been hospitalized for any mental health reasons?

Do you currently use alcohol, marijuana or other substances or drugs?

Do you partake in plant medicine:

Have you ever attempted suicide?

Have you recently had thoughts of suicide?

Has anyone close to you ever attempted or committed suicide?

Have you ever been physically, emotionally, or sexually abused?

Do you have people that you can turn to for support?

Personal or Relational Concerns

May I have your permission to thank the person who referred you to me? ?

Frequently Asked Questions

Contact Me

Ask a question or book an appointment below.
For emergencies call 911 or visit your nearest hospital

P.O. Box 4558, Arcata CA 95518

contact@the-listener.com