Counseling Services ONLINE Intake Form

Intake Form

AFTER you have paid for your requested services via PayPal, please complete and submit the following Intake Form. You will be contacted within 24 hours. Thank you.

PayPal Receipt ID: (located on your paid receipt) *

Your Email: *

Your Phone Number (preferred contact number) *

Your Name: *

Your Home Address *

Your City *

Your State *

Your Zip Code *

How soon would you like your counseling/coaching session? *
As soon as possible
Within 48 hours
Within 72 hours

TIme Zone you reside in: *

For phone & chat sessions only: preferred DAYS

For phone & chat sessions only: preferred TIMES

Date of Birth: *

Age: *

How did you hear about Counseling Services ONLINE?

Please introduce yourself to me. *

Please describe the issue for which you are seeking counseling. Include any detail that comes to mind. Include a time frame so that I know how long your issue has been affecting you. *

How would you describe your current family situation? Who are the most important people in your life? *

How would you describe your childhood? *

Briefly (2-3 sentences) describe your profession or work history. *

Have you ever contemplated or attempted suicide? *
Yes
No

If you indicated "Yes" above, please provide details.

Have you ever been hospitalized for any mental health or addiction issues? *
Yes
No

If you indicated "Yes" above, please provide details.

What hesitation or fears do you have regarding counseling?

Define a counseling/coaching goal. What is the MOST IMPORTANT thing you would like to achieve through online counseling/coaching? *

Is there anything else you would like me to know about you?

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Dr. Melissa Arnott Counseling Services Online

Hope. Change. Become.

Counseling Services Online