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Intake Tool
Form 2 of 4

Instructions

  1. This entire packet must be completed by, or for, each individule participating in any service provided by BCHH.

  2. If this form is being filled out by an adult for a minor child or a dependent adult under the guardianship of the one filling out the form, the child or dependent adult's name and address are to be used in Section A and your information must be provided in Section B.

  3. If you are simply assisting a person who cannot complete the form on their own, your information must be provided in Section B.

Baymeadows Center for Hope & Healing, Inc. (BCHH)

General Counseling/Coaching Intake Packet

FORM 2

History

Section A

Employment & Education

Section B

Family Dynamics

Some of the information in this section may be used to evaluate your rate plan.

Section C

Medical Information
Have you ever been diagnosed wth a mental condition?
Have you ever attended counseling or psychotherapy?

Section D

Family History

Section E

Spiritual History

I testify that the information provided herein is honest and accurate to the best of my recollection.

After you click Submit, you will be taken to the next required intake form.

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