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Intake form
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Name
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Email address
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What is your preferred method of communication?
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Phone
Email
Video Call
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What is your age?
What is your gender?
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Male
Female
Non-binary
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What is your current occupation?
Have you previously received counseling or therapy?
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Yes
No
If yes, please briefly describe your experience.
What are the main issues you would like to address in counseling?
How did you hear about holistic soul counseling services?
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Referral
Social Media
Search Engine
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Are you currently taking any medications for mental health?
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Yes
No
If yes, please list the medications.
What are your expectations from counseling?
Which service or services are you interested in?
Please select at least one option.
Trauma-informed counseling
Telehealth counseling
LPC-A Group supervision
Initial consultation for $150
Follow-up consultation for $100
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