Professional, caring, and convenient counseling at your finger tips

Online Counseling and Life Skills

New Client Intake Form Page One

Please complete a short intake form before beginning counseling services with OCLS for the first time.  This will help your counselor prepare for your first session.  It is also necessary to gather some brief demographic information.  This information is kept STRICTLY confidential and is only used in accordance with the mental health code, in case a client poses a danger to themselves or someone else.

**If you are seeking couples counseling, BOTH individuals must fill out separate Client Intake Forms.

 

 

 
Full Name:
Home Address:
Primary Phone Number:
Full Email Address:
Date of Birth:
Reason for Counseling Request:
Describe Past Psych History:
List current meds and doages:
How did you hear about us: