Disclaimer
The information collected in this professional service intake process is intended solely for initial assessment and planning purposes. It does not constitute medical or psychological advice and should not replace consultation with qualified health professionals. Users are responsible for seeking appropriate guidance tailored to their individual needs and circumstances. The content is provided as a general example and may require adjustments to adhere to local legal and ethical standards. We assume no liability for any misinterpretation or misuse of this information without proper professional oversight.
Please note: This is a sample Counselling Intake Form for California, created for informational purposes only. Actual forms may vary based on specific practice requirements and legal considerations.
Counselling Intake Form (California) Sample
Client Information:
Name: ________________________________
Date of Birth: __________________________
Address: ________________________________
Phone: _________________________________
Email: _________________________________
Emergency Contact:
Name: ________________________________
Relationship: ___________________________
Phone: _________________________________
Presenting Concerns:
Please briefly describe the reasons for seeking counselling:
______________________________________________________________________________
______________________________________________________________________________
Medical and Psychiatric History:
Are you currently under medical or psychiatric treatment? Yes / No
If yes, please specify: ________________________________________________
Consent and Agreement:
I consent to participate in counselling sessions and understand the confidentiality terms. I acknowledge that my information will be handled in accordance with California privacy laws.
Signature: ________________________________
Date: ________________________________
Additional Notes or Special Instructions:
______________________________________________________________________________
______________________________________________________________________________