Counseling Center Intake Form

This form is required for your first visit to the Counseling Center at Chelten (CCC). You can fill it out online, or you can download it here to print and bring with you. 

This form is for individuals, the Couples Intake Form can be found here.

Personal Information

Type your full name here if you will consent to our discussing your needs with your pastor as necessary.

Contact Information

Address
Phone
Emergency Contact

Description of the Presenting Problem

RecentlyA few months (6 or more)YearsSince childhood
Choose one
mildmoderateserioussevere
Choose one
(eg., death of a loved one, problem with work or school, relationship ending, past trauma or abuse, affair, etc.)
Enter "none" if there are not any.
For each issue please include: Dates, Problem, Treatment, Whether or not you were hospitalized
If yes, complete 11a & 11b. If no, move on to 12.
New fieldset
For each include: Name, Years seen, For what issues, Whether or not it was helpful.
We may want to consult with your previous counselors or psychiatrists.
For each medication include: Medication, dosage/frequency, person prescribing, how long you have taken medication, and whether it is helpful

Family Information

For each family member you must include their name, age, and occupation (if applicable). Enter "none" if you live alone.
Enter "none" if there are not any.

Agreement & Signature

I have carefully read this information and agree to all the stated terms and conditions. I also agree that all the information on my personal data form is true and complete to the best of my knowledge. I understand that I am responsible for the a fee per session.

By typing your name in the field below, you are agreeing to the statement above. Your signature will be asked for in person on your first appointment.