Intake form

Name *

Email address *

What is your age?

What is your gender?

What is your primary reason for seeking counseling?

Please select at least one option.

Anxiety

Depression

Stress management

Relationship issues

Trauma

Grief

Substance abuse

Self-esteem

Have you previously received counseling or therapy?

If yes, please provide details about your previous counseling experience.

What is your preferred method of communication?

Please select at least one option.

Phone

Email

Text

Do you have any specific goals for counseling?

Are you currently taking any medications for mental health?

If yes, please list the medications you are currently taking.

What is your occupation?

Do you have any medical conditions that we should be aware of?

Which service or services are you interested in?

Please select at least one option.

Individual counseling

Couples therapy

Family counseling

Additional questions or comments

Nova Counseling Group PLLC