New client intake

Your answers to the questions presented here will give us some preliminary information about you enabling us to prepare for your first meeting with a Therapist at CRSH. If you have not sent the completed form to us by email, please bring it with you to your first session.

What type of therapy/counseling are you pursuing at this time?*
Please share with us your reasons for seeking psychotherapy/counseling at this time: (check all that apply)

In your own words, briefly describe your reasons for seeking therapy/counseling*:

May we contact you and leave a message at this number?*

May we contact you & send information to this email address?*

Gender*:
Race

Religion

Marital Status*

Romantic / Sexual Orientation*
Children
Employment Status*:
IF YOU ARE IN A RELATIONSHIP, PLEASE PROVIDE INFORMATION ABOUT YOUR PARTNER/SPOUSE

May we contact you and leave a message at this number?

May we contact you & send information to this email address?

Gender:
Race

Religion

Marital Status

Romantic / Sexual Orientation
Employment Status:

By signing this agreement, you acknowledge that you have filled out this form truthfully and to the best of your ability.

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