LGBTQIA+ Counseling Intake Form
Please fill out the LGBTQIA+ Counseling Intake Form to help us better understand your needs and preferences. All information is kept confidential and is used solely to support your counseling experience.
Full Name
*
First Name
Last Name
Pronouns
Please Select
She/Her
He/Him
They/Them
Ze/Hir
Prefer not to say
Other
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Best way to contact you
Email
Phone
Text/SMS
What brings you to counseling?
*
Preferred counselor (if any)
Preferred days/times for sessions
How did you hear about us?
Please Select
Friend/Family
Online Search
Social Media
Community Organization
Other
Anything else you'd like us to know?
Submit
Should be Empty: