Debra L. Poepping, M.A., LMFT
If you would like to print out an intake form to complete by hand, simply
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.
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How would you like me to contact you?
Date of birth
Children (Please include name and age)
Who lives in your household currently?
Do you have a primary physician?
When was your last physical exam?
Are you currently under medical care?
Please identify current use and frequency of the following;
Please check any of the following struggles that pertain to you
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