COUNSELING IN-TAKE FORM

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GRACE Counseling In-Take Form

First name

Preferred Name

Last name

Birthday

Email

Select an Address

Home Phone

Select if okay to leave message

Cell Phone

Select if okay to leave message

Work Phone

Select if okay to leave message

Gender

Marital Status

How long have you been in this relationsip?

How many times have you been married?

How many times has your spouse/partner/fiance been married?

Family Dynamics

Describe why you are seeking counsel and what you hope to accomplish.

How were you referred to GRACE Counseling?

Do you attend church?

Where?

In case of emergency, the therapist may contact:

Description of problem(s): The following is a list of areas in which you may be experiencing some difficulty. Please select any of the symptoms that apply to you or help to describe a problem you are having.

Anxiety

Appetite Issues

Avoidance

Crying Spells

Depression

Excessive Energy

Fatigue

Recent Sickness

Hallucinations

Loss of Memory

Irritability

Libido Changes

Loss of Interest

Panic Attacks

Racing Thoughts

Relationship Issues

Headaches or Head Injury

Sleep Changes

Increased Use of Substances

Other:

Please add an additional notes here:

I have received a copy of the HIPPA Notice of Privacy PracticesView Privacy Policy

I have received the GRACE Counselig Policy StatemetView GRACE Counseling Policy Statement

Payment Assurance Policy: Should you fail to pay for a session scheduled with Dr. Sullivan, you authorize GRACE Counseling to charge your credit card for the session fee, or 50% of the session fee for no-show or failure to cancel with 24-hour notice.

Client Signature

Spouse/Parent/Guardian Signature

Today"s Date

Thank you!

We have received your form.

Global Relief Association for Crises and Emergencies

Phone: 478-351-0117

Email: info@globalreliefassociation.com

Mailing Address:

PO Box 677

Millen | Ga | 30442

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