Become A Client

Home
Owner
Black Mental Health Professional Pathway
Social Architecture
Professional Development
Executive Coaching
Counseling
Contact
Become A Strategic Partner

Home
Owner
Black Mental Health Professional Pathway
Social Architecture
Professional Development
Executive Coaching
Counseling
Contact
Become A Strategic Partner

Client Intake form

* Indicates required field

Today's Date *

Service Type *

Individual Therapy CTSS Services ARMHS Services

Client Name *

First

Last

Date of Birth *

Insurance Provider *

Policy number *

Phone Number *

Group number *

Email *

Parent/ Guardian Name (If unnder 18) *

First

Last

if under 18

Address *

Line 1

Line 2

City

State

Zip Code

Country

Emergency Contact *

First

Last

Emergency Contact Number *

Choose Any area you are experiencing stress *

family/children other relationships partner Employment School Living Situation

Comment *

Physical *

Difficulty sleeping Trembling or shaking Soreness of muscles Nausea/ stomach problems Night terrors

Mood *

Feeling down or sad Feeling helpless or hopeless Fatigue/ low energy loss of appetite Increased appetite/ over eating Lack of motivation Thoughts of suicide or self-harm Anger outbursts

Anxiety *

Racing thoughts Worry Feeling nervous or on edge Shortness of breadth/ tightness of chest Irritability Difficulty concentrating Heart racing

Behavior *

Hearing voices Perfectionism Paranoia Risk taking/ need for excitement Different sexual partners Repetitive behaviors/ obsession or compulsions

Submit