CONFIDENTIAL CLIENT INTAKE FORM

PERSONAL INFORMATION
Name:  						Date: 
Full Address: 
Home Phone:  			Cell Phone: 
Birthdate: 		
Email address: 
Referral source: 
Why are you seeking career counseling?  What are your goals for this initial
 career counseling appointment?


EDUCATION BACKGROUND
Graduate
School 		Degree 	  Major 	  Dates 	  Completed? 
Undergraduate
School 		Degree 	  Major 	 Dates 	  	Completed? 
Special certificates or training


EMPLOYMENT HISTORY
Please ATTACH RESUME, if you have one. 



OTHER 
Are there any physical or psychological issues that would impact your ability
 to obtain or maintain employment?  If so, please elaborate.



What are your hobbies and interests outside of work?
	



Kathy Lindblom, MA
Career Counselor
408-219-4747