Clint McKnight Counseling

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Counseling and psychotherapy for individuals, couples and families.

Book a consultation

Counseling and psychotherapy for individuals and couples.

Home
About
Specialities
Blog
Contact

Schedule an Appointment

Counseling Intake Form

Please fill in the Counseling Intake Form and we’ll get back to you.

Counseling Intake Form

Name

Age

Phone

Address

How is your general health?

Are you under a doctor's care?

Are you taking any medications? If yes, please list below.

Have you ever been hospitalized for a mental illness?

Check any of the following conditions that apply below:

Chronic Conditions

Smoking Habit

Drinking Habit

Drug Habit

Cannabis/Marijuana Habit

What is your occupation?

Relationship status

Single

Married

Divorced

Widowed

Living with partner

Number of marriages

Spouse/Partner Name

Do you have a family history of Alcoholism or Domestic Violence?

History of sexual addictions or sexual abuse?

Have you experienced past trauma? If so, explain

Religious upbringing

Is Religion/Spirituality currently an important part of your life?

Would you like spiritual elements/disciplines incorporated into your therapy?

Are you currently experiencing strong emotions? If yes, describe

Do you make decisions based on your emotions? How does this work for you?

Have you been treated for emotional disturbances? If yes, when?

Have you had any thoughts of suicide? If yes, when? **If you are currently having thoughts of suicide, please dial 911 or go to the nearest emergency room.**

Why have you decided to reach out for help?

How long has this been a problem for you?

Any previous therapy/counseling?

What do you hope to achieve with therapy?

Thank you for filling out the Counseling Intake Form. We will get back to you as soon as possible.

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Home
About
Specialities
Blog
Contact

Contact Info:

clintmcknightcounseling@gmail.com

(405) 509-9041

Serving all of Oklahoma

Schedule an Appointment

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Counseling and psychotherapy for individuals, couples and families.

Counseling and psychotherapy for individuals and couples.

Counseling Intake Form﻿

Counseling Intake Form

Counseling Intake Form