General Assessment Intake Form

Purpose: This form is designed to help us understand your needs and ensure that FATHATORCH INC. provides the best possible support and guidance.

Name

First Name

Last Name

Age

Preferred Contact Method

Phone

(###)

###

####

Who Referred You?

Are you currently experiencing any distress or challenges that require immediate support?

Yes/No, IF YES - PLEASE EXPLAIN

How did you hear about us?

Have you ever received services from FATHATORCH INC. or attended any of our workshops before?

Line

Which of the following best describes your current situation? (Select all that apply)

Which package or service best fits your needs?

Do you fully understand the services being offered?

YES

What are your primary goals for seeking support from FATHATORCH INC.?

Would you like to be connected with a mentor or peer support group?

YES