Counseling Client Intake Form

Information you will need

• What gender do you identify as?
• Do you practice a religion?
• What’s your marital status?
• How long have you been in your current relationship?
• How would you rate your relationship?
• How many marriages have you had?
• Are you employed?
• What’s your employer’s name?
• What’s your occupation?
• What’s your salary?
• What’s your employer’s street address?
• In what city is your employer located?
• In what state is your employer located?
• What’s your employer’s ZIP code?
• What’s your employer’s phone number?
• Have you ever been in the military?
• Do you have combat experience?
• Which branch of the military?
• How long did you serve?
• How were you discharged?
• What’s your first family member’s name?
• What’s your relationship to your first family member?
• What age is your first family member?
• Does the first family member live with you?

…and 157 more fields in the PDF.

Completed by the client.

The form includes 2 signature lines.