Our online intake form contains four sections and requires approximately five minutes to complete.

We believe in the sanctity of your privacy and keep all information confidential.

If you have not scheduled your first appointment, our office will call you shortly afterwards to confirm individual availability.

Please remember to bring your health insurance card with you at your first appointment.

If you would prefer to request a recommendation before submitting your intake, our directors are glad to help.

If you prefer to print our form to deliver by hand or post, you may download it here.










  1. Employment & Insurance Information
  2. (this information is often on the back of your insurance card)
  3. (if listed on insurance card)

  4. Personal & Medical Information
  5. (if applicable)

  6. Mental Health History
  7.  


The Center for Counseling Arts

Where the quality of care matters & counseling is an art