Client Intake Forms

Dear Client,

You have just taken a very positive step by deciding to seek counseling.  We are happy that you have chosen The Maple Counseling Center (TMCC) and want to take a moment to tell you a little about this remarkable nonprofit agency.

We started in 1972 when concerned Beverly Hills volunteers began working on the problems caused by teenage drug abuse.  Now we are considered one of the most comprehensive and innovative community mental health and counseling centers in the country.

The Center is open to you regardless of where you live.  Fees for counseling are on a sliding scale, based on your ability to pay.  As you know, we do ask that you prove financial need with appropriate documentation.  Since we have an annual budget of more than $1 million, client fees help keep the Center open.  The rest of the revenue comes from grants, fundraisers, and donations.  Every time a client is seen, it costs the Center significantly more than our average fee per session for counselor supervision, training, and overhead expenses.  You can and should discuss any concerns regarding your financial status with your counselor, especially if your financial situation changes or improves.  Additionally, once per year your fee will be re-evaluated and if it is determined you are able to pay more, your fee may be adjusted.

More than 600 clients are seen each week in individual, couple, family, or group therapy.  We offer parenting classes and support groups for divorce, seniors, women’s issues, bereavement, and other relevant topics.  The Center recognizes the special needs of seniors with a senior peer counseling program for those over the age of 62.  The Center has outstanding programs for families and their children.  In the Beverly Hills School District, our counselors provide one-on-one and group sessions.  Volunteers run highly effective after school Community Circle groups to help children enhance self-esteem and communication skills.

Our intern training program is highly sought after and attracts top candidates seeking licensure as PhDs, social workers, and marriage, family, and child counselors.  The Center has an excellent reputation for its intensive supervision and training curriculum.

We invite you to learn more about the Center.  Feel free to ask about the many services available for you and your family.  Welcome to the Center – we hope it will be a positive experience for you.


Dr. Lorraine Rose
Interim Clinical Director 


The Intake forms may be downloaded from the list below.
Please choose the appropriate form.


**For a couple’s intake session, please fill out two individual intake forms. 

** Parents and Guardians, please fill out the Additional Counseling Information form for your child or adolescent who is seeking counseling.

Individual Intake Packet

Couple Intake Packet

Family Intake Packet

Adolescent/Child Intake Packet 

Additional Adolescent/Child Counseling Information Form

Group Intake Packet