Life Focus Center

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Complete Intake Form

Intake Form

Life Focus Center

Initial Intake Screening

Contact Us

Full Name

Age

Phone

Preferred Method of Contact:

Call

Text

1. What brings you to counseling at this time?

2. Have you experienced any of the following? (Check all that apply)

Ongoing Anxiety or Panic

Persistent sadness or hopelessness

Trauma (past or recent)

Grief or Loss

Abuse (emotional, physical, sexual, spiritual)

Relationship or family conflict

Parenting concerns

Anger that feels out of control

Faith or spiritual struggles

Other

If other was checked, please share what feels safe to share:

3. Safety & Severity Check (past 6 months)

Thoughts of harming yourself

Thoughts of harming someone else

Self-harm behaviors

Suicidal thoughts (even if passive or fleeting)

A suicide attempt

Hospitalization for mental health reasons

Feeling emotionally overwhelmed most days

Feeling unable to function in daily responsibilities

If any are checked, please share what feels safe to share:

Free Text

4. Current Stability & Support

Do you feel safe right now?

Yes

Unsure

Do you have supportive people in your life?

Yes

Some

Very limited

Seeing another counselor?

Yes

Taking psychiatric medication?

Yes

5. Anything else you feel is important for us to know right now?

Thank you for completing the LFC initial intake screening.

One of our counselors will get back to you within 24 hours.

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Life Focus Center

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Moorestown Location

(609) 864-9300

301 N. Church Street, Suite 101

Moorestown, NJ 08057

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Galloway NJ Location

733 E. Lily Lake Rd. Galloway, NJ 08205