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Elm Cove (Midlands) ltd
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Intake form
Help us serve you better
Name
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Email address
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Date of birth
Gender
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Male
Female
Non-binary
Prefer not to say
Current living situation
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Living with family
Independent
Supported living
Primary diagnosis
Please select at least one option.
Anxiety
Depression
ADHD
Autism Spectrum Disorder
Bipolar Disorder
PTSD
Previous support services received
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Counseling
Psychotherapy
Medication Management
Occupational Therapy
Social Skills Training
None
Emergency contact name
Emergency contact phone number
Preferred method of communication
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Phone
Email
In-person
Text
What skills would you like to develop?
Please select at least one option.
Life skills
Social skills
Vocational skills
Emotional regulation
Independent living
Do you have any specific goals for your care plan?
Which service or services are you interested in?
Please select at least one option.
Individualised care plans
Multidisciplinary team support
Family Involvement
Trauma Informed Supported Living
Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT)
Vocational and Life Skills Training
Additional questions or comments
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