Intake form

Name *

Email address *

What is your preferred method of contact?

What are your primary concerns or reasons for seeking counseling?

Please select at least one option.

Anxiety

Depression

Relationship Issues

Stress Management

Trauma

Self-Esteem

Life Transitions

Have you previously attended counseling or therapy?

Please specify your preferred days for appointments.

Please select at least one option.

Monday

Tuesday

Thursday

Friday

Saturday

What time of day do you prefer for your appointments?

Please select at least one option.

Afternoon

Evening

Do you have any specific goals for therapy?

Are you currently taking any medications for mental health?

If yes, please list the medications you are taking.

Do you have any allergies or medical conditions that we should be aware of?

Additional questions or comments

Quintessential Counseling, LLC