Client Intake Form

Client Intake Form
CLIENT INFORMATION
Name*
First Last
Age*
Date of Birth*
Date Format: MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email Address*
Enter Email Confirm Email
Home Phone*
Cell Phone*
Work Phone*
Gender*
- Female
- Male
Preferred Method of Contact*
- Home Phone
- Cell Phone
- Work Phone
- Email Address
Student*
- Yes
- No
Name of School*
Referred By (if any)
First Last
EMERGENCY CONTACT INFORMATION
Emergency Contact*
First Last Relationship
Phone*
Email*
Enter Email Confirm Email

Please briefly describe the reason for which you are seeking services from OHL at this time.*
Which specific services of programs are you seeking from us?*
- Workshops/Community Discussions
- Mentoring
- Life Coaching
- OHL Counseling
- Mediation
Please briefly describe what you hope to accomplish from these services and/or programs.
Client Signature*
Date*
Date Format: MM slash DD slash YYYY
Parent/Guardian Signature
Date
Date Format: MM slash DD slash YYYY