Mental Health Counseling Checklist Form
Please complete the following checklist to help us understand your current mental health needs.
Client Full Name
*
First Name
Last Name
Date of Session
*
-
Month
-
Day
Year
Date
Presenting Issues (select all that apply)
*
Have you previously received mental health counseling?
*
Yes
No
Current Medications (if any)
*
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Additional Notes
*
Submit
Should be Empty: