MHRC | Intake Form Intake-Form

MHRC Intake Form
Client Name:
Date of Birth:
Driver's License No. & State:
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?
Are you currently on or have you ever been on psychiatric medication(s)?
If yes, please list the medication(s), your diagnosis and your medical doctor's information:
What service(s) would you like MHRC to provide?
yesno
yesnon/a
yesno