Initial Intake

Consent to Treatment form may be downloaded here.

Tell me a bit about you.

    First Name

    Last Name

    Birth Date

    Gender
    MaleFemale

    Address



    Phone

    Email

    How did you hear about me?

    Have you been in counseling previously?
    YesNo

    Are you currently attending meetings for recovery?
    YesNo

    If yes, how long?

    What is it in your life you desire to change?

    Have you read ”Ready to Heal“?
    YesNo

    How would you assess your readiness for change?
    Extremely EagerEagerInterested in Knowing MoreHesitantNot really interested in changing: someone else wants me to change

    Additional Remarks