Client Intake

Please take a minute to review, complete, and submit. Thank you!

Name *
Address *
What is your marital status? *
...please indicate dates, spouse (or spouses if you've been married more than once), and children, including who has custody of minor children.
Do you have a history of: *
Have you ever considered suicide? *
Have you ever attempted suicide? *
Please check any of the following which are currently causing you difficulty:
Please explain.