EACH PERSON ATTENDING COMPLETES A SEPARATE INTAKE FORM.
 
  Community Wellness Partners of NC PLLC
809 N. Lafayette St., Suite A, Shelby, NC  28150
1446 E. Gaston St. Suite 101, Lincolnton, NC 28092
           
Phone: (704) 284-0554
Email: info@cwpofnc.com

CONFIDENTIAL CLIENT INFORMATION

 
 
Date of Birth:  
 
 
 
     
 How do you prefer we contact you?(Mark all that apply)        
 
Only Add Numbers that you want to receive a message to: (voice/text)
 
 
 
 
 
 
 
 
 
 
 
 


 
Legally Responsible Person ( For Minor Clients)[SWTC must have a copy of official custody documents on file prior to serving a minor]
 
 
 
   

 
 

Please check all that apply in your current family (only yourself, spouse, and/or kids). History of:
 
 

Please check any/all that apply anywhere in your family tree (your parents, relatives, spouse's family, etc.). History of:
     
 
 
 Current Medications, include name of medication, start date, reason, dosage, and prescribing doctor:
Please list previous counseling, include name, dates attended, reason and diagnoses
 
Please briefly describe what you hope to accomplish as a result of working with your therapist:
 
Please briefly describe why you chose SWTC over another therapy practice:
 
How did you come to hear about Shelby Wellness and Therapy Center? (check all that apply)
                     
Please list below any internet search engines or websites you visited in your therapist search:
      
 
Please check any/all issues which are a concern for you today:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
What do you consider your strengths?
 
What do you consider your areas of improvement?