Intake Form, Hadley Counseling

Personal Information

Name *

Email Address *

Date of Birth

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Cell Phone

Home Phone

Work Phone

I give permission to be contacted at these numbersYesNo

Name of Emergency Contact

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone

I give permission to contact this person at these numbersYesNo

Comment

Desired outcome or expectations of treatment (changes you would like to make, how I can help)?

Please list any people, organizations or resources you feel will help you achieve your goal

Please list any potential barriers to achieving your goal(s):

Are there special, unusual and traumatic or abuse circumstances that affected your development?YesNo

If yes, please explain

Please enter any medications, your dosage and who prescribed them

Please list any prior counseling or therapy treatment

Any hospitalizations, suicidal thoughts/attempts, alcohol/drug treatment

Self help/support groups (AA, Al-Anon, Overeaters Anonymous, NA, Etc.)

Any past or current legal issues

eSignature *

I have received a copy of Elizabeth Hadley’s Professional Disclosure Statement and have had it explained to me.