Migrant Youth Counseling Intake
Personal Information
Full Name
Date of Birth
Age
Gender
Male
Female
Other
Prefer not to say
Pronouns
Country of Origin
Primary Language
Contact Information
Address
Phone Number
Email
Emergency Contact Name
Emergency Contact Phone
Migration Background
Date of Arrival
Reason for Migration
Accompanied By
Family Information
Family Structure
Current Living Arrangement
Education
Current School
Grade/Level
Education History
Health & Wellness
Physical Health Concerns
Mental Health Concerns
Present Concerns
What brings you to counseling?
Goals for Counseling
Goals