Counseling Intake Form

JC Christian Counseling

1821 Oregon Pike Suite 212 / Lancaster, PA 17601 / Office: (717) 278-8326 / Fax: 1- 866-285-7198

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Letter from the Director

Employment


Date:			Date of Birth	Social Security Number


Name:			First	Middle	Last

Address:

Phone: (H)

(Email)

Employer/School:

Occupation/Grade:

Denomination:

Church:

Who referred you to this office?

Who will be responsible for payment?

Phone: (H)

(Email)

Have you ever been convicted of a felony?

If yes, for what reason?

Military Service:

Dates:

Did you serve in combat?

FAMILY INFORMATION
If married or in a significant relationship, how many years?

Spouse or partner’s name:

Do you have any children, and how many?

MEDICAL INFORMATION

Have you had therapy in the past?

When?

With Whom?

Are you presently seeing a local therapist?

If so, who are you seeing?

Have you ever been given a diagnosis for a mental health condition?

If so, what condition?

Are you currently prescribed medication for any mental health conditions?

Have you recently had thoughts of suicide?

Have you developed a plan of how this would be carried out?

Have you ever attempted to harm yourself or others in the past

Has anyone ever raised concerns about you and drug/substance use and/or excessive use of prescription drugs or alcohol consumption?

If so, who and when?

CURRENT CONCERNS

What do you consider is your most significant difficulty or problem today?

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Request Information

Phone:

Mobile:

Electronic Forms

Initial Forms

Online Care Plans

Release of Information

Services & Refund

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