Moving ForwardLife ServicesIndividual & Family Counseling Service

Client Forms

Please complete the appropriate forms prior to your first appointment. Submitting forms in advance helps us serve you better and ensures your session starts on time. If you have any questions about which forms to complete, please call our office at 770-383-2754.

Fillable Client Forms

Complete your Intake Referral Form right here on this page and submit it securely to our office — no printing required. Your responses go directly to our referrals team.

Complete the form below and click Submit. Required fields are marked with an asterisk.

Who is completing this form

Name of person completing form *

How are you related to the client?

Identifying Information (for individual receiving services)

Name *

Date of Birth *

Address

Sex

Marital Status

Home Phone

Work Phone

Social Security Number

Household Income ($)

Who referred you to Moving Forward Life Services?

Race

Language of Choice

Religious Affiliation

Do you have a disability?

YesNo

Does the office accommodate your needs?

YesNo

If the therapist should be aware of any special treatment considerations due to gender, age, sexual orientation or cultural, religious, national, racial, or ethnic identity, please explain:

Family History

1. Were drugs or alcohol a problem in your family when you were growing up?

YesNo

2. Do you or another family member have a history of alcohol or drug problem?

YesNo

3. Please describe your current alcohol consumption

4. Was there any type of abuse (physical, sexual, domestic or emotional) in your family or home?

YesNo

5. Have you or any other family member experienced any type of abuse?

YesNo

Legal History

Please describe any involvement you have had with the legal system (arrests, convictions, probation, parole)

Current Family Information

Spouse/Significant Other - Name (first and last)

Spouse/Significant Other - Date of Birth

Spouse/Significant Other - Lives with you?

YesNo

Children - Live with you?

YesNo

Others living in the household

Military service

YesNo

Occupation

Current employer

Goals

1. What are your strengths?

2. What are your weaknesses?

3. What goals would you like to see reached?

Insurance Information

Primary insurance - Group number

Primary insurance - Policy number

Secondary insurance - Group number

Secondary insurance - Policy number

Signature

Type your full legal name as your signature *

Client name (print)

Date *

I have read the Notice of Privacy Practices included in the Intake Referral Form and consent to Moving Forward Life Services using my protected health information for treatment, payment, and healthcare operations as described.

For your convenience, completed forms may be brought to your first appointment or submitted via our secure contact form above. Please do not email sensitive personal health information.

Request Forms or Ask a Question

Need forms emailed to you, or have a question before your appointment? Fill out the form below and our office will respond within one business day.