Client Intake Form - Fairview Counseling of Chester County LLC

If the client is a minor, please provide the name/address/phone of a parent or guardian below.
Is the client under 18 years old?*
- Yes
- No
Name*
Relationship to Client*
Address*
Street Address City State ZIP Code
Client Phone Contact Information*
Phone Type Phone Number OK to Leave a Message?
Name of financially responsible party*
Responsible Party Phone Number*

Family Members
Name Age Relation

Please list the name, ages, and relation to you of each person living in the household.

Medical History
Have you experienced any major illnesses, operations, injuries, or hospitalizations?*
- Yes
- No
Details
Please describe any medications you are currently taking that address mental health issues
Name of Medication Dosage Prescriber
Please describe your reason for seeking counseling services
What do you hope to accomplish in our work together?
Have you received counseling/therapy previously?*
- Yes
- No
When did you previously receive counseling?
With whom did you previously receive counseling?
What were your previous diagnoses?
*
I have read and agree to the website privacy policy.

Phone Type	Phone Number	OK to Leave a Message?

Phone Type	Phone Number	OK to Leave a Message?

Name	Age	Relation

Name of Medication	Dosage	Prescriber

Fairview Counseling of Chester County