Counseling Intake Form Name of Minor* First Last Age of Minor*Emergency Contact* First Last Preferred Contact Email* Preferred Contact Phone*Okay to leave message at Preferred Contact Phone Number?*YesNoPreferred Contact Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What is your relation to the minor?*How did you find the BBC Counseling Center, or who referred you?*Please describe what concerns you have regarding the minor.*Briefly describe the minor's relationship with God*Has the minor ever had any previous counseling experience?*YesNoIf yes, please describe the reason(s) for previous counseling.Has the minor ever had any serious thoughts about suicide?*YesNoHas the minor ever attempted suicide?*YesNoDoes the minor have any natural support (friends, relatives, etc.) that they are currently relying on? If yes, who?What days of the week and times of day work best for the minor to meet?*Is there anything else you wish the counselor to know?