Individual | Discovery Counseling Center of the San Ramon Valley

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New Client Intake Form

New Client Intake

Name(Required)

First

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 Pronouns

Race/Ethnicity

Service Requested(Required)

In-Person or Telehealth(Required)

Therapist Preference

Gender/Service Specialty/Other

Availability for sessions

Please indicate if you have any flexibility around these times.

Home Address(Required)

Street Address City ZIP Code

Additional Parent/Guardian Information

If minor of divorce: choose applicable custody situation.

Shared Legal

Sole Custody

Other

Additional Family Member Information

If family includes minor of divorce: choose applicable custody situation.

Shared Legal

Sole Custody

Other

Other Participant Information

Who 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.

Discovery Counseling Center

Danville

Town and Country

Shopping Center

115A Town and Country Drive
Danville, CA 94526

San Ramon

Dougherty Station

Community Arts Center

17011 Bollinger Canyon Road
San Ramon, CA 94582

Copyright © 2023 | All Rights are Reserved.

SCOTT LUCIA

Wealth Management at Andrews, Lucia Wealth Management LLC

Affiliation:

Tassajara Valley Little League

ROBERT COMBS

Real Estate Advisor, Compass

Affiliations:

Town of Danville Planning Commissioner
Board Member, Leadership San Ramon Valley
President, Danville Rotary, Town of Danville Design Review Board Member
Board of Directors
League of California Cities, California State University at Chico Alumni Board of Directors
Parent Advisory Council
CSU
Past President

MICHAEL COPELAND

Managing Director, Cushman & Wakefield

Affiliations:

San Ramon Valley Thunderbirds
San Ramon Valley Girls’ Athletic League Softball
Contributor to Alive Magazine

MARK DAVIS

Tri- Counties Bank- Senior Vice-President

Affiliations:

American Heart Association
United Way
Habitat for Humanity
St. Anthony’s San Francisco
San Francisco and Sacramento Food Banks
Sacred Heart Community
Past Board Member California Symphony
Past

JENISE FALK

Retired San Ramon Valley Unified School District Principal

Affiliations:

President of the Friends of Discovery(Thrift Station)
Kappa Kappa Gamma Alumni Association
San Ramon Valley Mental Health Advisory Council.

NEWELL ARNERICH

Town of Danville, Town Council Member, AD Architects, Inc., President & Co-founder

Affiliations:

Leadership San Ramon Valley
Board Member & Past President
Danville-Sycamore Valley Rotary Club- Member & Past President
AIA
American Institute of Architects
NACRB
National Council of Architectural Registration Board
Danville Area Chamber of Commerce
San Ramon Valley Mental Health Advisory Council.

KATHY CHIVERTON

Retired Executive Director Discovery Counseling Center

Affiliations:

Leadership San Ramon Valley Board of Directors
Rotary Club of Danville
Contra Costa County Measure X Community Advisory Board Member

MARIE HALL

Licensed Social Worker; Retired Clinical Director
St. Anne’s Catholic Church

Affiliation:

Friends of Discovery

MITCHELL HOPSON

Vice-President of Finance, Zearn

Affiliations:

Diablo Black Men’s Group (past Treasurer)
San Ramon Valley Diversity Coalition (founding member)
Leadership San Ramon Valley
Board of Directors
Youth sports coach

DAVID KRAVITZ

Affiliations:

Director of Student Services
San Ramon Valley Unified School District

N. S. LEE

Retired Project Manager, Kaiser-Permanente

Affiliations:

Toastmasters’ International
Project Management Institute

Claire Humphrey

Retired Pediatrician: Valley Community Health Center and Blackhawk Medical Group

Affiliations:

Marriage Mentor Community Presbyterian Church
Spiritual Mentor CityTeam Oakland

ANDY LI

Board Member, Contra Costa Community College District

Affiliations:

President
Civic Leadership USA
President
API Coalition, Board of Directors
Leadership San Ramon Valley
Steering Committee
San Ramon Valley Diversity Coalition
Rotary Club of Dougherty Valley/San Ramon

NEAL MITCHELL

Community Volunteer

Affiliations:

Hall of Fame Board Member Animal Rescue Foundation
Board Member Love for Margot Foundation
Past Board Member Mercator Medical Systems
Past Board Member Injoy Media Corporation

NISHI MOONKA

Chief of Staff/Head of Purpose and Culture at Blue Beyond Consulting

Affiliations:

Quail Run Learning Fund Vice President
PTA

SARAH NIX

Attorney, Certified Specialist in Estate Planning, Probate & Trust Law By the State Bar of California Board of Legal Specialization

Affiliations:

Past President, Board of Diablo Valley of Estate Planning
Iron Horse Mother’s Club
AAUW, Volunteer St. Isidore’s Parish
East Bay Trust &amp, Estate Lawyers

JILL PURCELL

Owner Purcell International – Food Importing Business

Affiliations:

San Ramon Valley YMCA- Past Board Member
Diablo Homeowner’s Association- Past Secretary
Dorris-Eaton School-Past PTA President
Green Valley School and Monte Vista High School- Past PTSA Member

PAT WILSON

Retired San Ramon Valley Unified School District Educator

Affiliations:

Sons in Retirement (SIRS)
100 Club of Contra Costa County
Community Presbyterian Church (CPC) Sponsor Program
San Ramon Valley Mental Health Advisory Council.

MARY VERSTRAETE

Retired from Banking

Affiliations:

Member of the Friends of Discovery
Thrift Station

GARY RIELE

Affiliations:

Principal
Riele Commercial Real Estate

ANN WILLOUGHBY

Retired Chief of Staff, University of California Office of the National Laboratories

Affiliations:

Treasurer Friends of Discovery Board (Thrift Station)
Quest Science Center Advisory Board
Livermore Lab Foundation
Expanding Your Horizons
Agape Village Foster Family Agency
American Association of University Women