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 (if minor, we require the first session to be with counselor and parent, no child. This allows for deeper understanding of family history and ability to gain insight into building relationships).*
Preferred Counselor*
Appointment Type
- In-Person-Arizona
- In-Person-Georgia
- Virtual
Referred By (if any)

Intake Form