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Laura Young, LCSW Counseling Services, P.C.
315 W. 57th St  Suite 310
New York, NY 10019
Email: Info@LLYoung.com
Tel: 212.581.9466

Client Intake Form

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At the end of the form, press send.

Basic Info
Name *
Name
Address *
Address
Mobile/Cell Phone *
Mobile/Cell Phone
Work Phone
Work Phone
Home Phone
Home Phone
Date of Birth *
Date of Birth
Family & Partnerships
1=Poor, 10=Excellent
If yes, how many? Please list their ages.
Do you have any brothers? How many?
Do you have any sisters? How many?
(eg: Oldest, Middle, Youngest etc.)
Education & Work
Academically and socially, as young people, we learn and develop so much from our peers, professors/teachers and coaches etc., please complete your recollection of your earlier educational experience(s):
Highest Grade/Degree
1= Most Important 5=Least Important
1=Most Important 5=Least Important
1=Most Important 5=Least Important (chess team, debate team, drama club etc)
1= Most Important 5=Least Important
1= Most Important 5=Least Important
1= tremendous dis-satisfaction/annoyance 10=great enjoyment/satisfaction with the school I attended
1= tremendous dis-satisfaction/annoyance 10=great enjoyment/satisfaction with the school I attended
1= tremendous dis-satisfaction/annoyance 10=great enjoyment/satisfaction with the school I attended
1= tremendous dis-satisfaction/annoyance 10=great enjoyment/satisfaction with the school I attended
1= tremendous dis-satisfaction/annoyance 10=great enjoyment/satisfaction with the school I attended
1= tremendous dis-satisfaction/annoyance 10=great enjoyment/satisfaction with the school I attended
Is there anything stressful about your current work?
General Health & Mental Health Information
Have you previously received any type of mental health services? *
Check all that apply. (eg: psychotherapy, psychiatric services, etc)
If you are currently taking any prescription medications, please list each medication & the reason.
How would you rate your current physical health? *
How would you rate your current sleeping habits? *
Please describe your faith or belief.
Family Mental Health History
Family History *
In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member's relationship to you in the space provided (father, grandmother, uncle, etc) Check all that apply
Please indicate the family member's health challenge & relationship to you in the space provided (father, grandmother, uncle, etc)
If any area checked "Yes," please provide any details that are important or useful for me to know
Indicate the kind of therapy you are requesting *
Check all that apply

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