New Client Intake Form Δ
If you are experiencing a life-threatening emergency — including thoughts of suicide or of harming yourself or others — stop and dial 911, or go to your nearest emergency room.
You can also call or text 988 to reach the Suicide & Crisis Lifeline, free and available 24 hours a day.
This form is not monitored around the clock and is not a way to request emergency or urgent care.
Client Information Tell us who you are and how we can reach you.
Is it OK to leave a voicemail?
Is it OK to send text messages?
Preferred method of contact
- Select - Phone call Text message Email
Emergency Contact Someone we may contact if we have a serious concern for your safety.
Type of Therapy Requested
Referral and Reason for Seeking Services
How did you hear about this practice? If you were referred, who were you referred by?
What are your goals for therapy?
Mental Health History These questions help us understand your background. Answer only what you feel comfortable sharing.
Have you ever seen a therapist or counselor before?
If yes, when and for what reason?
Have you ever been hospitalized for mental health concerns?
If yes, please share when and where
Current mental health symptoms (check all that apply)
Other symptoms or concerns not listed above
Have you ever engaged in self-harm?
Have you ever attempted suicide?
Have you experienced any major life changes or losses recently?
Current medical conditions or diagnoses
Do you have any allergies (medication, food, etc.)?
Substance Use Do you currently use any of the following? If so, please note how often.
Have you ever had concerns about your substance use?
Family and Social History
Who lives in your household?
Support system (friends, family, community)
Will there be any legal involvement in your treatment — for example probation, parole, family court, CPS?
If yes, please provide details
Are you currently working?
Highest level of education completed
Insurance and Billing Information
Availability for Appointments
Consent and Acknowledgement
How your information is handled
The information you share here is used only to prepare for your care and is submitted over an encrypted (HTTPS) connection. We do not sell or share it for marketing. If you would prefer to give this information by phone or in person instead of online, call us at 631-600-3216 and we will take it that way.
Accessibility
We want this form to work for everyone. It is built to meet WCAG 2.1 Level AA and works with keyboards, screen readers, and screen magnification. If any part of it is difficult to use, or you need this information in another format or would like help completing it, call 631-600-3216 or email dynamiccounselingli@gmail.com and we will assist you or complete the form with you. We welcome feedback on accessibility barriers and will work to resolve them.
Submit Intake Form
