Geriatric Counseling Consent and Intake Form
Consent for Counseling
I have read and understood the counseling consent information and agree to participate in geriatric counseling sessions.
Client Information
First Name
Last Name
Date of Birth
Age
Address
Phone Number
Email
Emergency Contact Name
Emergency Contact Phone
Medical & Psychiatric History
Current Medical Diagnosis
Current Medications
Primary Care Physician Name
Primary Care Physician Phone
History of mental health diagnosis or treatment
Counseling Needs & Goals
Reason for seeking counseling
Counseling goals
Any additional concerns
Signature
Client Name (Printed)
Signature
Date