{"id":536,"date":"2026-02-09T03:11:02","date_gmt":"2026-02-09T03:11:02","guid":{"rendered":"https:\/\/momentum-counseling.org\/?page_id=536"},"modified":"2026-02-09T03:18:58","modified_gmt":"2026-02-09T03:18:58","slug":"intake-form","status":"publish","type":"page","link":"https:\/\/momentum-counseling.org\/index.php\/intake-form\/","title":{"rendered":"Intake Form"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row css=&#8221;.vc_custom_1457477817242{padding-top: 100px !important;padding-bottom: 50px !important;}&#8221;][vc_column width=&#8221;1\/6&#8243;][\/vc_column][vc_column width=&#8221;2\/3&#8243;]<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_4' >\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Intake Form<\/h2>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_4'  action='\/index.php\/wp-json\/wp\/v2\/pages\/536' data-formid='4' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_4_27\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full hipaa_forms_first_name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_27'>First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_4_27' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_28\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full hipaa_forms_last_name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_28'>Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_4_28' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_4\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_4'>Middle Name or Initial<\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_4_4' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_6\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Date Of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_4_6' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_4_6_1_container'>\n                                            <input type='number' maxlength='2' name='input_6[]' id='input_4_6_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_4_6_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_4_6_2_container'>\n                                            <input type='number' maxlength='2' name='input_6[]' id='input_4_6_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_4_6_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_4_6_3_container'>\n                                            <input type='number' maxlength='4' name='input_6[]' id='input_4_6_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_4_6_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_4_29\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">----<\/h3><\/div><div id=\"field_4_14\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_14'>Relationship Status<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_14' id='input_4_14' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Select one:' >Select one:<\/option><option value='Married' >Married<\/option><option value='Single' >Single<\/option><option value='Divorced' >Divorced<\/option><option value='Partnered' >Partnered<\/option><\/select><\/div><\/div><div id=\"field_4_15\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_15'>Spouse or Partner&#039;s Name (if applicable)<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_4_15' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_21\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_21'>Please describe briefly what you are wanting help with:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_21' id='input_4_21' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_4_31\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">----<\/h3><\/div><fieldset id=\"field_4_33\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you had previous counseling?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_33'>\n\t\t\t<div class='gchoice gchoice_4_33_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Yes'  id='choice_4_33_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_33_0' id='label_4_33_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_33_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='No'  id='choice_4_33_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_33_1' id='label_4_33_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_34\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_34'>If yes, please explain more details (when was it, how long did you go, what did you go for, how was the experience, etc).<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_34' id='input_4_34' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_4_35\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_35'>What does your spouse\/partner do for work?<\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_4_35' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_59\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_59'>Provide details on your current marriage\/relationship? How long have you been together\/married? How would you describe your relationship? etc.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_59' id='input_4_59' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_4_39\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_39'>Provide details on any past marriages\/relationships (how long did it last, when did it end, what was the relationship like, etc).<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_39' id='input_4_39' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_4_40\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_40'>List how many children you have and their ages. Also describe which relationship they are from (your current relationship or a past relationship) and the quality of your relationship with them.<\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_4_40' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_41\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Any military history?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_41'>\n\t\t\t<div class='gchoice gchoice_4_41_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Yes'  id='choice_4_41_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_41_0' id='label_4_41_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_41_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='No'  id='choice_4_41_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_41_1' id='label_4_41_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_44\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_44'>If yes, what branch, what was your experience, when did you serve?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_44' id='input_4_44' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_4_45\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_45'>What do you do for work?<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_4_45' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_46\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_46'>How long have you been there?<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_4_46' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_47\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_47'>How do you like your job?<\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_4_47' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_49\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_49'>Describe any religious or spiritual beliefs you have.<\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_4_49' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_50\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_50'>List any hobbies or interests you have.<\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_4_50' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_60\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_60'>Any past trauma or abuse? If so, please provide any details that you are comfortable sharing.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_60' id='input_4_60' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_4_53\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_53'>List any medications (if applicable). Also describe how long you have been on them and how effective you feel they have been.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_53' id='input_4_53' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_4_51\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_51'>Describe any medical problems or health concerns.<\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_4_51' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_54\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_54'>Who prescribes your medications?<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_4_54' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_55\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_55'>Describe any substance use history (past and present). Include the frequency and quantity of use.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_55' id='input_4_55' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_4_56\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_56'>Describe your family of origin. Are your parents still married? What was their relationship like? List your siblings and their ages. Describe your relationship with your parents and siblings.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_56' id='input_4_56' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_4_57\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_57'>Describe your social life? Do you have many friends? How often do you do things with them?<\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_4_57' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_58\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_58'>Describe your educational background. 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