FORM – Initial Assessment – Refreshing Waters Counseling

Date*

First Name*

Last Name*

Age*

Date of Birth*

MM

DD

YYYY

Address*

City*

State*

Zip Code*

Primary Phone Number*

Secondary Phone Number

May we leave a message?*

Email*

Emergency Contact Info

Emergency Contact Name*

Emergency Contact Phone*

Emergency Contact Relationship*

Reason for Visit

What brings you to counseling and how long has it been a concern?*

Current Diagnosis