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?
Assigned (Legal) Gender
Do you have kids
if yes, how many
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: