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SOCIAL ANXIETY SUPPORT GROUP INTAKE FORM
www.AvedianCounselingCenter.com (818) 383-1399
Thea Brown
Sherman Oaks - Glendale - Woodland Hills
Client Registration
Full Name:
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DOB:
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Age:
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Address
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City
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State
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Zip Code
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Mobile Phone:
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Is it okay to leave a message?
Yes
No
Email Address:
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Family Physician:
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Phone Number:
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Psychiatrist (if any):
Phone Number:
Assigned (Legal) Gender
Gender Identity
Preferred Pronouns
Sexual Orientation
Racial Identity
Marital Status
Do you have kids
Yes
No
If so, how many
What age(s)
Presenting Problem:
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Previous Therapy:
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Briefly Describe Living Situation:
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Employment:
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Date of First Symptoms:
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What are the Symptoms?
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Current Medications:
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Other Pertinent Drug/Alcohol History:
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Person to Contact in Emergency:
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Phone Number:
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Referred By:
Date of First Office Visit: