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Intake Form

Please fill out and submit the Intake Form prior to your first session.  It's important to be as thorough and accurate as possible so I may assess your needs during our first session.

Full Name

Phone

Address

Email

Birthday

Biological Gender

Male

Female

Marital Status

Single

Married

Divorced

Separated

Widow/Widower

Spouse's Name

List previous marriages

List children's names and ages

Do you attend church?

Yes

No

How long have you attended church?

Have you sought counseling before?

Yes

No

Are you currently seeing a psychiatrist?

Yes

No

Thank you!

We have received your submission.

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Intake Form Continued

List medications you have been prescribed by a psychiatrist

List the reasons you are seeking help

Which services are you interested in?

What do you hope to accomplish?

List any continuing issues or struggles

Describe your sleep patterns

Have your eating habits changed lately?

Yes

No

Describe the frequency of the following habits:

Alcohol

Daily

Weekly

Occasionally

Never

Thank you!

We have received your submission.

Error

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Light The Way Soul Care

Contact: Lisa@LightTheWaySoulCare.org

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