Counseling Request Form

1

Present problem or issue that brings you to counseling:* This field is required.

2

Are you currently experiencing suicidal thoughts?* This field is required.

YESNO

3

Have you ever.....

had a history of suicidal thoughts/desires

attempted suicide

engaged in self-injury

been hospitalized for mental health/emotional issues

4

Have you had counseling in the past?

YESNO

5

Are you experiencing any of the following?

Sadness

Hopelessness

Lack of Motivation

Low Levels of Energy

7

Name

First Name

Last Name

8

E-mail

9

Phone Number

Area Code

Phone Number

10

Date of Birth

11

Relationship Status

Single

Married

Other