Capstone Counseling, LLC

Confidential Intake Form

Please correct the errors described below.

Identifying Information

If married more than once, list each marriage & divorce/death by indicating YOUR AGE at each event.

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Medical Information

Have you ever taken any of the following? (Check all that apply and if possible, list dates)

Family History

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Education

How long have you been employed in your present job?

If you’re not currently working, how long have you been unemployed?

Counseling History

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