Kelly F. Dennis MS LPC NCC
Treatment Intake
Date: ________________
Personal Information
Name
Date of Birth
Age
Family Information (Spouse, Children, or Anyone Living in the Home)
Name and Relationship
Date of Birth
Age
(grade if applicable)
Identifying Information
Address
City
Home Phone Number
Cell Phone Number
Marital Status
Other Information
Occupation (Include School If a Student)
Spouse/Partner’s Occupation
State / Zip Code
When Married / Divorced

Family Referral Services