Samantha Salver Counseling PRE CONSULTATION FORM Client Name * First Name Last Name Preferred name to be referred to as First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Main phone number (###) ### #### Email * Gender identified by client Spoken language/ reading literacy language Person completing the form and relation Date of birth MM DD YYYY School (highest education) Job (current or last) Past/present therapy experiences What happened that lead to you contacting us? Short term or Long term? How long has this been occurring? What changes or interventions have you tried before calling for professional help? Are there any diagnosis? Mental health Physical Chromosomal DNA Medications Who do you live with and relation? Who are other important people in your life? a. Best friend(s) b. Other family members c.Teachers/therapists/neighbors/coworkers/etc.. What do you expect to get out of therapy? What might be some barriers to achieving your goal? How would you describe what you need help with: Learning issues Depression Anxiety Hallucinations (visual or audio) Trouble concentrating Trouble getting along with others Substance abuse Memory issues Other If you selected 'Other', please explain: Marital status Individuals strengths Individual challenges Thank you!
