Skip to content
Grace Counseling LLC.
Meet Morgan
Service Plan
New Client Form
Please fill out the form below.
I deeply appreciate the honor and trust that is provided in the counseling relationship and look forward to working with you. These questions will help me get to know you better.
← Back
Thank you for your response. ✨
Full name
(required)
Date of Birth
(required)
Email
(required)
Address
(required)
Phone number
(required)
Preferred method of contact
Select one option
Phone
Text
Email
Are you in a current relationship? (If so, please list dates together)
Former partners and dates together:
Do you have children? Please list their names and ages if you are comfortable.
Parents names and ages:
Are they still married? Where do they live?
Do you have siblings? If so, what are their names and ages?
Current employment/volunteer work:
Closest friends:
Current employment/volunteer work:
Do you work with a psychiatrist/APRN? (If yes, who?)
Current PSYCH medications:
Any spiritual beliefs or practices?
Hobbies/groups you belong to:
Major illnesses/recent surgeries:
Past Hospitalizations:
Past therapy experiences and dates of service:
Personal or family member addictions:
History of abuse/neglect/trauma:
How did you hear about me?
Are you interested in Telehealth?
Select one option
Yes
No
What days/times are you available:
What do you want to talk about in therapy?
Is there anything else you would like me to know?
Submit
Δ
Grace Counseling LLC.
Sign up
Log in
Copy shortlink
Report this content
Manage subscriptions
Grace Counseling LLC.