New Client Intake Form New Client Intake First Name(Required) First Last Name(Required) Last Is this intake for yourself?(Required)If filling out for another individual please do so only if client is a minor or dependent adult. Yes No Email(Required) Phone(Required)Name of Client First Last Client Date of Birth(Required)Preferred PronounsRace/EthnicityHispanicWhite, non-HispanicBlack/African AmericanAmerican Indian/Alaska NativeAsianNative Hawaiian/Other Pacific IslanderMultiracialOtherService Requested(Required)Individual (Adult)Individual (Minor)FamilyCoupleSenior GroupGrief GroupLGBTQ+ Teen GroupIn-Person or Telehealth(Required)In-PersonTelehealthEitherTherapist PreferenceAvailability for sessionsHome Address(Required) Street Address City ZIP Code Additional Parent/Guardian InformationIf minor of divorce: choose applicable custody situation. Shared Legal Sole Custody Other Additional Family Member InformationIf family includes minor of divorce: choose applicable custody situation. Shared Legal Sole Custody Other Other Participant InformationWho lives in the home?Has the client been in mental health therapy before? Yes No If yes please add details.Has the client been seen in Discovery Counseling Center or SCIP before? Yes No If yes please add details.What brings the client to therapy at this time?(Required)Is the client on any medication? Yes No If yes please add details.Does the client have/had a problem with any of the following? Drug Use Alcohol Use Gambling Sex/Love Disordered Eating Self Harm Other If a box is check please add details.If other please add details.Does any of your family members have/had a problem with any of the following? Drug Use Alcohol Use Gambling Sex/Love Disordered Eating Self Harm Other If a box is checked please add details.If other please add details.Is or has the client had suicidal or serious thoughts about harming others? Yes No If yes please add details.Is or has someone in your family had suicidal or serious thoughts about harming others? Yes No If yes please add details.Has the client ever been hopsitalized due to a mental health condition? Yes No If yes please add details.Does the client have any know physical and/or intellectual disabilities? Yes No If yes please add details.Are you a Kids Country Employee?If Yes, I authorize Discovery Counseling Center to verify my employment status with Kids Country Human Resources. Yes No Is this a referral from SRVUSD SARB? (School Attendance Review Board)? Yes No Is this a referral for SRVUSD ASP? (Alternatives to Suspension) Yes No Are you a resident of the city of Danville?Confirmation of residency will be confirmed at completion of intake. Yes No EmailThis field is for validation purposes and should be left unchanged.
