MHRC | Intake Form

MHRC Information form

Client Name:

Date of Birth:

Address:

Phone:

Email:

Did anyone refer you to MHRC? If yes, please list.

May we leave a message at this number?  

CLIENT INFORMATION                                                                   Must be completed by the client (unless under the age of 16)

May we use this email for correspondence regarding this inquiry/intake?  

Street, City, State & Zip Code

PREVIOUS COUNSELING

Have you attended any previous counseling or treatment?

If yes, where and when?:

Did you complete the program?

What service(s) would you like MHRC to provide?

Welcome to Mental Health Resource Center...we care for your health!

YesNo

YesNo

yesno

yesnon/a