Intake Form – Professional Disclosure Statement LPC Santos

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Intake Form – Professional Disclosure Statement LPC Santos

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What type of counseling do you need? *

Counseling for my child
Couples counseling
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Counseling for myself

If you are not certain, please list what you feel would be the most important primary service to start with. The intake coordinator will support you during the scheduling process.

Please specify the clients age range. *

Under 6
7 to 12
13 to 17
18 to 25
26 to 39
40 to 60
61 +

Please check multiple age boxes if needed.

Please share what brings you to therapy. *

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