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BIPOC Support Group Intake Form
www.AvedianCounselingCenter.com (818) 990-0999
ANITA AVEDIAN, M.S., LMFT, LMFT 38403
DESTINY JOHNSON, MS
Sherman Oaks - Woodland Hills - Glendale - Hollywood
(818) 426-2495
Client Registration
Name:
*
DOB:
*
Age:
*
Full Address:
*
Cellular Phone:
Is it okay to leave a message?
Yes
No
Email Address:
Psychiatrist (if any):
Phone Number:
What is your racial identity?
*
Presenting Problem:
*
In previous years, have you ever attended therapy? If yes, when was the last time?
*
What is your employment status?
*
Currently employed
Furloughed / Laid off
Unemployed
Other
What are your main stressors?
*
What medications are you taking? Please indicate what it's for.
*
What are your coping strategies? For example, meditating, praying, and/or exercising.
*
What is your experience with racial discrimination?
*
Person to Contact in Emergency:
*
Phone Number:
*
How did you hear about our group?
Date of Enrollment: