Counseling Intake Form - Loretta Forbes

Please complete the form below if you’re interested in my Counseling Services!

First & Last Name *

Phone Number *

Email Address *

Date of Birth *

Mailing Address *

Country *

Your Occupation *

Company you currently work for *

Religious Affiliation *

Who referred you? How did you hear about my services? *

Are you married? *

If yes, what is the name of your Spouse/ Significant Other?

What is your anniversary date (if applicable)?

Do you have children? *

If yes, what are the name(s) and age(s) of your children?

What challenges are you facing emotionally or mentally right now? *

What are the three biggest changes you want to make in your life in the next 3 months? *

What are the three biggest dreams/aspirations you want to accomplish in your life over the next 3 years? *

What do you most want to achieve during our initial counseling period? *

What most threatens to hold you back from achieving these goals? *

What do you like to do in your spare time (i.e. hobbies, extracurricular activities)? *

What are your greatest strengths? *

What are your areas of improvement? *

Have you thoroughly reviewed the information above? Submitting this form strengthens your dedication. *