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Intake Tool
Form 2 of 4


  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



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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