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Client Information

NOTE: If the client is 18 years of age or older, the client is the only person permitted to complete and sign this form. If the client is under 18, the parent or guardian must complete and sign this form.

Client's legal Name
Date of Birth
What services are you looking for within Serenity? (check all that apply)
Relationship to Client?

Client demographics

You can select only 1 options.
Gender
You can select only 1 options.
Serenity Therapists
Select a maximum of 2 therapists
Appointment Time Preference (select all that apply):
Who is the counseling for?

Presenting Problem

Will you need your provider to complete any paperwork or documentation related to your mental health care (e.g., FMLA, disability, ESA, workplace/school accommodations, or other forms)?
How would you like to pay for your services (check all that apply)?

Primary Insured Member Information:

Private Pay
Are you related to a Serenity staff member?
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