Adult & Young Adult Intake Form

Client Information

First Name
Last Name
Date of Birth
Age
Occupation / School Currently Attending
Other Schools Attended

Contact Information

Email
Phone

Household

Who do you currently live with?
Reason for Seeking Services

Are you currently taking any medication?
YesNo

Medication & Prescribing Doctor

Have you ever completed an evaluation?
YesNo

Evaluation Purpose & Results

Areas of Concern:
AnxietyDepressionBehavioralSocial SkillsSelf-esteemAngerOther

How did you hear about Shine Bright Counseling?

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Shine Bright Counseling Required Forms

Please review the following forms before completing this intake:

Open Shine Bright Counseling Required Forms

Please confirm that you have read and agree to the following:

Consent to Treatment and Confidentiality formComplaint Process formTelemental Health Informed Consent formNotice of HIPAA Privacy Policies formConsumer Consent Disclosure form

Electronic Signature (Acknowledgment Required)
I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law.

Submit Young Adult/Adult Intake Form