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Intake Form

 Hall Counseling & Associates


Contact Jill at for any questions or concerns. 

If you ever need to cancel an appointment within 24 hours please text at 713-859-1246. 



Personal Information
Marital Status
Medical Information
Past drug history?
Family Information
Do you or your relatives have a history of any of the following?
Depression - Relative
Depression - Me
Substance Abuse - Relative
Substance Abuse - Me
Anxiety - Relative
Anxiety - Me
Therapy Information
Do you currently experience difficulty with any of the following?
Have you ever experienced sexual abuse or any negative sexual experience?
Sometimes when people are in so much pain they start to have thoughts about hurting themselves or committing suicide. Has this happened to you recently?

Thanks for submitting!

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