Client Intake Formpet loss dcJessica Kwerel, LPC, LCPCwww.petlossdc.com jessica@petlossdc.com 202-642-2682 please complete the form below Name First Name Last Name Email Date of Birth MM DD YYYY Address Please describe what happened and how I can support you Have you ever seen a therapist before? 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 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!
