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
Is it okay to leave a message?
Psychiatrist (if any):
What is your racial identity?
In previous years, have you ever attended therapy? If yes, when was the last time?
What is your employment status?
Furloughed / Laid off
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:
How did you hear about our group?
Date of Enrollment: