JULISSA EDWARDS COUNSELING

Intake Form

Hello! Please fill out this short intake so I can better assist you. I look forward to working with you on your healing journey!

We require a minimum of 2 sessions a month. $175 Each Session ( for a single person or a couple ). We require a 3 month minimum commitment. We do not accept insurance at this time. If this is within your budget and you would like to continue, please answer the intake questions below. Payments can be made monthly via debit or credit.

First Name *

Last Name *

Email *

Phone

Date of birth *

In your own words, what is the reason for seeking care at this time? Describe any current problems as you see them. *

Have you previously suffered from this problem/issue? If it has been an ongoing issue, how long would you state this has gone on for? *

What are your goals for therapy / what would you like to accomplish? *

If Yes, have you sought out counseling before? If so, what practices did you like best? Anything in particular you weren’t fond of in your last counseling experience?

Current Symptoms (please highlight/circle all that apply) *

Anxiety

Anger

Appetite Issues

Avoidance

Cry Spells

Depression

Excessive Energy

Fatigue

Guilt/Shame

Hallucinations

Impulsivity

Irritability

Libido Changes

Loss of interest in previously enjoyed activities

Low self-esteem

Marital/Relationship Issues

Panic attacks

Racing thoughts

Risky (unsafe) Activity ?

Sleep Changes

Any history of abuse? (Emotional or physical) *

Do you have children and/or a spouse/partner? If yes, how is your relationship with them? *

What is your highest level of education? *

What medication are you currently using (if any)? *

Are you aware of any previous mental health diagnoses? *

Do you have any history of drug use? *

Please list an Emergency Contact below. *

How did you find out about Julissa Edwards Counseling? *

*Please check your email immediately after submitting this form. You will receive your contract.

After signing the contract you will receive

1. email with a copy of your contract and a 2nd email to schedule your sessions and pay your invoice.

Please check your spam and junk folder as well if you do not see our emails *

Make sure to save our email to your contact list.

Thank You ,

Julissa Edwards Counseling Team