Client Intake Form — JL Resources for Women

Client Information

Client Name

Date of Birth

Age

Phone Email Address / City / State Emergency Contact Name Emergency Contact Phone Relationship to Client

Reason for Seeking Support

What brings you to JL Resources at this time? Other

Current Situation

Briefly describe what you are currently walking through. How long has this been affecting you? What have you already tried that has or has not helped?

Goals for Our Time Together

What do you hope to gain from your sessions? What would moving forward look like for you?

Support and Safety

Do you currently have supportive people in your life?

Yes No Somewhat

Please explain.

Are you currently in any immediate danger or unsafe situation?

Yes No

If yes, please explain.

Have you had thoughts of harming yourself or someone else?

Yes No

If yes, please explain.

Faith and Spiritual Support

Would you like faith-based encouragement included in your sessions?

Yes No Sometimes

Are there any spiritual concerns, questions, or church experiences you would like to share?

Counseling and Coaching Understanding

JL Resources provides women's life coaching, listening support, encouragement, and goal-focused guidance. I understand that JL Resources is not a medical, legal, or licensed mental health counseling service.

Client Initials

I understand that if I am in crisis, danger, or need medical or mental health treatment, I should contact emergency services, a licensed counselor, doctor, or crisis hotline.

Client Initials

Information shared in sessions will be treated with care and respect. I understand confidentiality may need to be broken if there is concern about harm to myself, harm to another person, abuse, neglect, or as required by law.

Client Initials

Session Preferences

Preferred session type

Phone Video Either

Preferred days and times Anything that would help you feel more comfortable during sessions?

Agreement

By signing below, I confirm that the information I provided is true to the best of my knowledge. I understand the purpose of JL Resources and agree to participate honestly and respectfully.

Client Signature / Typed Name

Date

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