Counseling Intake Form

Intake Form
Welcome to Whole Hope Christian Counseling, LLC (EIN: 81-4201353). Please complete the intake form below and submit prior to your first session to help aid in the process of your care.

Please note: information provided on this form is protected as confidential information.
Personal Information
Name*
Parent / Legal Guardian (if under 18)*
Today's Date*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone*
May we leave a message?*
- Yes
- No
Cell/Work/Other Phone*
May we leave a message on your Cell/Work/Other Phone?*
- Yes
- No
Email*
Date of Birth*
Gender
Age*
Preferred Counselor*
Referred By (if any)

Intake Form