Mental Health Counseling Checklist Form

Mental Health Counseling Checklist Form
Please complete the following checklist to help us understand your current mental health needs.
Client Full Name
First NameLast Name
Date of Session
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Presenting Issues (select all that apply)
Have you previously received mental health counseling?
Current Medications (if any)
Emergency Contact Name
First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Additional Notes
Should be Empty: