Lock & Key Wellness
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Counseling Intake Form

Please take a few moments to complete this form so Jessica has the context she needs before your first session. Be accurate and specific — and skip anything you'd rather share in person.

Your responses are sent directly to Jessica by encrypted email. Submit only what you're comfortable sharing online — anything else can be discussed at your first session. See our Privacy Policy and Terms for details.
Client information

Optional. Skip this if you'd prefer to share it in person at your first session.

Emergency contact
Presenting problem
On the scale below, please indicate how upsetting your situation is right now.
MildSevere
Have you been in therapy before?
Please check all of the symptoms you are currently experiencing:
Personal information
Military service

Mark stepsiblings with 'S' and half-siblings with 'H'.

Health history
Do you have any current health problems?
Have you been on any medication during the past six months?
Have you ever attempted suicide?
Have you ever been sexually abused?
Have there been any pregnancies that have not gone full term?
Have you ever been hospitalized for major health, psychological, drug, or alcohol problems?
Referral & payment
May we thank the person for the referral?
Consent for treatment

Your electronic acknowledgment below has the same effect as a handwritten signature.

I, the undersigned, have voluntarily applied for and agree to participate in counseling services. The ultimate responsibility for fees rests with the undersigned client or parent/guardian. Clients are requested to provide 24-hour notice of cancellation. Without such notice, clients will be billed for the professional time at the regular hourly or half-hour rate. My acknowledgment below indicates my understanding of the foregoing.