Counseling Center Client Check-in Form
Please complete this form to check in for your counseling session. Your responses will help us provide you with the best possible support.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Have you visited our counseling center before?
*
Yes
No
Counselor you are scheduled to see today
*
Please Select
Dr. Smith
Dr. Lee
Dr. Patel
Other
Appointment Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Reason for Visit (select all that apply)
*
Stress/Anxiety
Depression
Relationship Issues
Academic/Career Concerns
Other
How are you feeling today?
*
Not well at all
1
2
3
4
5
6
7
8
9
Very well
10
1 is Not well at all, 10 is Very well
Emergency Contact Name and Phone Number
*
Is there anything else you would like your counselor to know before your session?
Check In
Should be Empty: