Client Intake Form - shieldmeeinc.org

Contact

Family

Clinical

History

Safety

Consent

Section 1 of 6

Contact Information

Please provide accurate contact details. Fields marked * are required.

First Name *

Middle Name

Last Name *

Date of Birth *

Age

Today’s Date

Cell Phone *

Home Phone

Work Phone

Email Address *

Street Address *

City

State

Zip Code

Employment

Your Employer

Your Occupation

Spouse/Partner Employer

Spouse/Partner Occupation

Referral

How did you hear about ShieldMee Inc.?

Section 2 of 6

Family & Support Network

Please list key family members and supports. Write N/A for any that don’t apply.

Relationship	Full Name	Age	Phone

Section 3 of 6

Clinical Presentation

Please describe what brings you to therapy. There are no wrong answers.

Presenting Concerns

What are your presenting symptoms and problems?

What are you hoping to change or accomplish through therapy?

Previous Treatment

Have you seen a therapist or counselor previously?

Have you ever had psychological testing or evaluation?

Current Treatment & Medications

Are you currently receiving treatment for any medical or psychological condition?

Are you currently taking any medications?

Section 4 of 6

Medical & Psychiatric History

Your history helps us understand your full clinical picture. Write “None” where not applicable.

Significant personal medical history

Significant family history (grandparents, parents, siblings, children)

Section 5 of 6

Safety & Legal

These questions are asked of all clients and are part of standard clinical care. Please answer honestly.

Your responses are confidential with exceptions required by Florida law (e.g., imminent risk of harm, abuse of a minor or vulnerable adult). If you have questions about confidentiality exceptions, please ask before completing this section.

Self-harm & Safety

Have you ever thought about seriously hurting yourself?

Have you ever been in a relationship involving pain or coercion (sexual or otherwise)?

Legal History

Are you currently or do you anticipate becoming involved in any legal situations?

Have you or any family member ever been in trouble with the law?

Have you made or do you wish to make any threats against any person?

Additional Comments

Is there anything else you would like your clinician to know?

Section 6 of 6

Authorization & Consent

Please read each item carefully, initial where indicated, and sign below.

Please Read and Initial Each Item

I understand that Eduardo Florez, LMHC is solely responsible for all billing, fee-setting, clinical documentation, record retention, and storage at ShieldMee Inc.

I understand my communications are privileged under Florida law with exceptions including: (1) risk of harm to self or others; (2) suspected abuse or neglect of a minor or vulnerable adult; (3) mental health at issue in a court proceeding; (4) court order or applicable law; and (5) consent given for billing, referral, clinical consultation, or legal purposes.

I agree to promptly communicate any dissatisfactions, complaints, or questions about my treatment or fees directly to Eduardo Florez, LMHC.

I consent to Eduardo Florez, LMHC using electronic communications (phone, email, VoIP, text, voicemail, etc.) without encryption, and to his use of AI tools to record or analyze communications for clinical and documentation purposes.

Electronic Signature

By signing below, you confirm that all information provided is accurate to the best of your knowledge and that you agree to the terms above. This electronic signature carries the same legal weight as a handwritten signature.

Print Full Name *

✓

Form Submitted

Thank you. Your intake form has been received. A copy is being generated for your records. Eduardo Florez, LMHC will follow up with you prior to your first session.