Client Intake Form

P. O. Box 3381, Fayetteville AR 72702
4257 N. Gabel Dr, Suite 2B, Fayetteville AR 72703
479-738-7059
Glenda Davis, MSC, LMFT, LPC – Therapist

Name (First) (Middle Initial) (Last)

Address

Apt, suite, etc.

Country

City

State

Zip code

Cell Phone

Home Phone if different

Age

Marital Status

School/Employment

Number of children and ages

Birth date

SSN

e-mail

Health Insurance Provider

Church Affiliation

Church Member

Yes

Briefly describe your reason for seeking help.

Who referred you or suggested you call?

When were you last examined by a physician?

List any health problems for which you are currently receiving treatment:

List all current medications: (include OTC Meds)

How much alcohol do you consume?

Do you use any marijuana or other drugs?

List any known mental health problems within your family or others who live in your home:

Name, Age, Relationship to You, Mental health issue

Person Giving Information's Name

Date

Signature