Client Intake Form Pet Loss DCJessica Kwerel, LPC, LCPC petlossdc.com jessica@petlossdc.com (202) 642-2682 Please complete the form below Name * First Name Last Name Phone * (###) ### #### Email address * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * Occupation Preferred gender pronouns Gender identity Relationship Status Do you have any children? Yes No If so, how old are your children? Name of pet(s) How old is/was your pet? What kind of animal is/was your pet? (dog, cat, horse, bird, etc.) What is/was the breed and gender of your pet? How long have you had/did you have your pet? Date of your pet's passing (if applicable) Do you have any other pets? If yes, what kind and how old are they? Have you ever seen a therapist prior to working with me? Yes No If yes, briefly describe what brought you into counseling Have you ever had any suicidal thoughts in your past? * Yes No If yes, how long ago? Are you currently having any thoughts about suicide? * Yes No Have you ever engaged in any form of self-harm? * Yes No If yes, please describe what kind and how often Do you currently engage in any form of self-harm? * Yes No If yes, please describe what kind and how often Are you currently taking any medications that would be helpful for me to know about? Yes No If yes, please list medication name, dosage, and how often its used Have you experienced any other significant losses in your life before? What are your goals in our work together? * What are some of your strengths? Is there anything else that would be helpful for me to know about you? Emergency contact name and phone number * Thank you!
