Confidential Client Intake Form: Name * First Name Last Name Date * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Home Phone (###) ### #### Work Phone (###) ### #### Cell Phone (###) ### #### Do NOT contact me by * Home Work Cell Email SEX * Male Female D.O.B MM DD YYYY Age SS # * Employer First Name Last Name Occupation Title * Hours Per Week * Years at Work * Level of Education * Do you regularly attend church, synagogue or other religious institution? * Yes No If yes, are you a member? Yes No Name of church/ institution Pastor First Name Last Name How did you hear about our services? Relational Information * Single Engaged Married Seperated Divorced Widowed How long if engaged, married, divorced or widowed? Number of previous marriages Number of your current spouse? Name of Spouse First Name Last Name Age * Spouse's Occupation Please write a brief description about your spouse * (i.e. angry, controlling, outgoing, and supportive) Please list all your children included step, adopted and foster children * ( Include their Names, Sex, Age or Year of Death, Relation, and Who they are living with) FAMILY OF ORIGIN: Please list your mother, father, brothers, sisters, stepfamily and or relatives who had a significant effect on your life (positive or negative). * Include their name, sex age or year of death, relationship, and description of them. Please identify any of the following you experienced in your family * Physical Abuse Emotional Abuse Sexual Abuse Abortions Gambling Drug/ Alcohol addiction Religious Upbringing Major losses Please describe the family that you grew up in * Name * Emergency Contact Information First Name Last Name Relationship: * Phone Number (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Counseling History If you have had any previous counseling, psychiatric treatment, substance abuse treatment, or residential inpatient care, please lists the names of the therapists and or programs Please provide the Name of Therapist/Program, The issued addressed, and the dates in treatment Has anyone in your family ever been treated or hospitalized for substance abuse, mental health issues or psychiatric conditions? * Yes No If yes please describe Have any of your family or friends attempted or committed suicide? * Yes No If yes, who and when? MEDICAL HISTORY: Name and address of current physician Date of last physical exam MM DD YYYY What was the outcome? Please list any conditions, illnesses or surgeries that might be relevant to your reason for seeking counseling Please list current medications you are taking even if use is seldom or as needed Include the name of medication, dosage, and reason for taking. PRESENT ISSUES AND GOALS Please describe why you are coming to counseling (issues, problems, symptoms, how long, etc.) Check any of the following symptoms or problems that you are currently or have recently experienced: * Stress Greif Verbal Abuse Impulsive Behavior Anxiety Chronic Pain Sexual Abuse Controlling Sexual Problems Fears Loneliness Sexual Addiction Obsessive Thoughts Depression Panic Indecisiveness Poor Connection Shyness Gender Identity Anger Fatigue Low Self-esteem Hearing Voices Loss of Appetite Bad Dreams Marital Problems Aggression Racing Thoughts Trouble Sleeping Apathy Rational Issues Eating Problems Physical Abuse Unwanted Memories Alcohol Use Feeling Worthless Emotional Abuse Loss of Control Pregnancy/Abortion Work Issues Financial Issues Spiritual Apathy Drug Issues Career Choices Loss Compulsive Behaviors Controlled by others See things others don't Indicate on the scale how distressing your problems are to you * "My Problems cause me minimal distress" Strongly Disagree Disagree Neutral Agree Strongly Agree "My Problems cause me moderate distress" Strongly Disagree Disagree Neutral Agree Strongly Agree "My Problems cause me extreme distress" Strongly Disagree Disagree Neutral Agree Strongly Agree Are you currently experiencing any suicidal thoughts? * Yes No Have you experienced suicidal thoughts or attempted suicide in the past? * Yes No Client Signature * Date MM DD YYYY Insurance Co. Name Health Insurance Information Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Insured ID # Group Policy # If insured is other than the patient: Insured’s Name First Name Last Name Insured’s D.O.B MM DD YYYY Insured’s Address Address 1 Address 2 City State/Province Zip/Postal Code Country Patient’s Relationship to Insured Self Spouse Child Other Insured’s Employers Name First Name Last Name Insured’s Employers Address Address 1 Address 2 City State/Province Zip/Postal Code Country Is there another health plan benefit? Yes No If yes, name them I authorize the release of any medical or other information necessary to process my health insurance claims. * sign name below Print Name * First Name Last Name Date MM DD YYYY Cancellation Policy If you fail to cancel a scheduled appointment, we cannot use this time for another client and you will be billed the entire cost for your missed appointment. A full session fee is charged for missed appointments or cancellations with less than a 24 hour notice. A bill will be mailed directly to all clients who do not show up for or cancel an appointment. Thank you for your consideration regarding this important matter. * I Agree Client’s signature * Date * MM DD YYYY Form Submitted!
