Certificates in: Play Therapy, Sexual Abuse and Trauma Recovery,

Marriage and Family Therapy, and

Canine Assisted Therapy
Licensed Mental Health Counselor MH 9099
924 N. Magnolia Ave, Suite 210 p 407. 312.8295
Orlando, FL 32803 f 407.704.7999
ehollingsworthlmhc@gmail.com
INTAKE ASSESSMENT
CLIENT NAME: Gender DOB AGE
Pronoun

GUARDIAN NAME: Gender DOB AGE

Pronoun

ADDRESS: Home Ph: ( )

Work Ph: ( )
CITY STATE ZIP: Cell or pager: ( )
EMERGENCY PERSON: ______________________ Phone:_________________________
Relationship to Client_________________________________________________________
Marital Status: Divorced Single Widowed Married Committed
Relationship Separated
Email:

EMPLOYER OCCUPATION

HAVE YOU BEEN IN THERAPY PREVIOUSLY? YES NO

If yes please list names of therapist and dates

PLEASE DESCRIBE THE REASON YOU ARE SEEKING THERAPY?

REFERRAL SOURCE: (For Therapist Use Only)

Diagnosis:
LATE CANCELLATIONS & MISSED APPOINTMENTS

I agree to provide 24 hour notice of cancellation for any appointments that I have
made. If I do not provide this notice, I agree that I am responsible for the cost of the
session for the time I reserved and prevented others from being able to use.
________________________________________ __________________________
Signed Date