R.E.A.C.H. Counseling New Client Intake Forms

Please fill out this intake form. Upon submitting this form you will be automatically directed to the REACH Intake and Screenings forms. These forms MUST be completed and signed online. These forms need to be completed and signed before you start services with R.E.A.C.H. Counseling. Then you will be contacted by R.E.A.C.H. to schedule your first appointment. Thank you for choosing R.E.A.C.H. Counseling.

R.E.A.C.H. New Client Intake form.

Name *

First

Last

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Brief Summary of Presenting Issue/s: (Please include current diagnoses and medications, if known) *

Goals for Counseling: *

Date of birth *

Gender Identity *

Sexual Orientation *

How did you hear about this site? *

Internet Search Advertisement Friend Other

If Other please specify: *

NAME OF YOUR HEALTH INSURANCE COVERAGE (PUT NONE IF NOT INSURED) *

Insurance Member ID *

Were you referred to REACH? If Yes then by who? *

Are you requesting a specific counselor, if so who? *

Have you used any non prescribed prescription or non prescription drugs or alcohol within the past 30 days? *

Yes No

Upon submitting this form you will be emailed or texted a link for the Intake and Screenings needed. Please complete and sign these forms. Services will not be able to start unless they are completed and signed.
Thank you for choosing R.E.A.C.H. Counseling!

R.E.A.C.H. COUNSELING
NEW CLIENT INTAKE

R.E.A.C.H. New Client Intake form.

RESTORING

EDUCATING

ADVOCATING

COLLABORATING

HOPE

R.E.A.C.H. COUNSELING​NEW CLIENT INTAKE

R.E.A.C.H. New Client Intake form.

RESTORING

EDUCATING

ADVOCATING

COLLABORATING

HOPE

R.E.A.C.H. COUNSELING
NEW CLIENT INTAKE