Debra Poepping, MA, LMFT - Counseling Services
Debra L. Poepping, M.A., LMFT
LF 60281197
Cell:  425-443-2380
 
 
If you would like to print out an intake form to complete by hand, simply click here for a printer-friendly form. Otherwise, please feel free to complete the electronic form below.
 
Please complete one form per adult.
Your answers to these questions are confidential. 
Please ask me any questions you may have in filling out the form.
Today's date
Full name
Home address
Mailing address
City/State/Zip
Phone
Cell
Home
Work
Email
How would you like me to contact you?
Date of birth
Occupation
Marital status
How long?
Partner/spouse's name
Children (Please include name and age)
Who lives in your household currently?
Do you have a primary physician?
Yes
No
When was your last physical exam?
Are you currently under medical care?
Yes
No
Please identify current use and frequency of the following;
Alcohol
Non-Prescription Drugs
Nicotine
Caffeine
Prescription Drugs
Please check any of the following struggles that pertain to you
Anxiety
Depression
Fears/Phobias
Eating Disorders
Sexual Problems
Suicidal Thoughts
Separation/Divorce
Relationships
Finances
Drug/Alcohol Use
Career Choices
Anger
Self-Control
Unhappiness
Insomnia
Religious Matters
Work/Stress
Health Problems
Cutting/Self-Mutilation
Thought Patterns
How were you referred to me
Have you seen a counselor before
If yes, please share Counselor's name and last date of visit
Was it helpful
Why or Why Not
Why are you seeking therapy now
What are you hoping to achieve with therapy
What do you do for relaxation and pleasure
What is the greatest source of stress in your life at this time
What is the greatest source of strength in your life at this time
Please list any significant losses, changes or events
Is there any additional information you would like to add at this time
Emergency Contact Information
Name
Phone
Address
Relationship