INTAKE

James A. Stover, M.Ed., L.P.C.C., C.R.C. Care Team Counseling 440.821.7380

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START NOW
Meet James
Telehealth
Specialization

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Professional Counseling in
Northeast Ohio

COUNSELING
INTAKE
FORM

Following are questions regarding your personal history. The purpose of this form is to gather initial background information in order to save time in your first session.

* Indicates required field

Name: *

Phone: *

Email *

Have you ever attended Counseling/Therapy Before? *

YES NO

If so, with whom? *

(Choose any / all that apply) (Optional) *

Attention Deficit Anger Anxiety Career Counseling / Employment Problems Conflict Resolution / Anger Management Depression Family Problems Habit Change Counseling / Personal Development Identity Concerns Learning Differences / Dyslexia Loneliness Problems with Intimacy Relationship Concerns / Couples Counseling Sexual Assault / Abuse Stress Management Worried About a Family Member / Friend with a Drinking Problem and / or Drug Abuse Problem

Additional Comments (Your Needs & Wants) (Optional) *

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If you are in a crisis or any other person may be in danger - do not use this site. These resources can provide you with immediate help.

Home
START NOW
Meet James
Telehealth
Specialization

​​​​Professional Counseling in​Northeast Ohio​

COUNSELING INTAKE FORM

​​​​

Following are questions regarding your personal history. The purpose of this form is to gather initial background information in order to save time in your first session. ​

If you are in a crisis or any other person may be in danger - do not use this site. These resources can provide you with immediate help.

Professional Counseling in
Northeast Ohio

COUNSELING
INTAKE
FORM

Following are questions regarding your personal history. The purpose of this form is to gather initial background information in order to save time in your first session.