Date: ___________________________

CLIENT NAME: ___________________________________________

PLEASE ANSWER THE FOLLOWING QUESTIONS:

(Please feel free to write on the back of this form)

1. What is your problem? (What brings you here?)

2. What have you done about it?

3. What do you want me to do? (What are your expectations of this counseling service?)

4. What brings you here at this time (Why now)?

5. Is there any other information I should know? (Recent losses, health problems, medication, drug or alcohol use)