Client Intake Form

Hope Arising Counseling PLLC

Please correct the errors described below.

Client Information

Are there additional contacts that you give your permission for Hope Arising Counseling to contact regarding your billing, scheduling, or emergencies?

Employment/Student Status

List all persons currently living in your household and any children not living with you:

Name Age Sex Relationship to you

Please tell us how you hope Hope Arising Counseling can help you.

Please tell us more about your mental health and medical history.

Please tell us about the important developmental and social details of your life.

Please tell us about your substance use history:

    Please upload a file

    Credit Card Information

    Your typed name below indicates that you have carefully read all pages and agree to all conditions of the informed consent for services, as well as received a copy of our Privacy Practices.

    Your information will be encrypted.