Counseling Intake FormPlease provide the following information and answer the questions below. Please note: information you provide here is protected as confidential information.Name:(Last) (First) (Middle Initial)Name of parent/guardian (if under 18 years):(Last) (First) (Middle Initial)Birth Date:Age:Gender: Male Female Address:(Street and Number) (City)(State)(Zip)Home Phone:May we leave a message? Yes No Cell/Phone:May we leave a message/text ? Yes No Email:May we email you? Yes No *Please note: Email correspondence is not considered to be a confidential medium of communication.Referred by (if any):Marital Status: Never Married Domestic Partnership Married Separated Divorced Widowed Please list any children/age:Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)? Yes No If you said "Yes", previous therapist/practitioner:How was therapy helpful?What prevented therapy from being helpful?List all prescription medication you are currently taking:List all non-prescription medication:GENERAL HEALTH AND MENTAL HEALTH INFORMATION1. On a scale of 1-10 (ten being highest) How would you rate your current overall health: 1 2 3 4 5 6 7 8 9 10 Please list any specific health concerns:2. On a scale of 1-10 how would you rate your current sleeping habits? (ten being most satisfied) 1 2 3 4 5 6 7 8 9 10 Please list any specific sleep problems you are currently experiencing:3. How many times per week do you exercise?What types of exercise do you participate in?4. Please list any difficulties you experience with your appetite or eating patterns:5. On a scale of 0 – 10 rate your current level of sadness: 0 1 2 3 4 5 6 7 8 9 10 Approximately how long have you been experiencing these feelings?6. On a scale of 0 – 10 rate your current level of anxiety or depression: 0 1 2 3 4 5 6 7 8 9 10 When did you begin experiencing anxiety?When have you experienced panic attacks?7. On a scale of 0-10 rate your current level of chronic pain: 0 1 2 3 4 5 6 7 8 9 10 Please describe:8. On a scale of 0 – 10 rate your level of weekly alcohol consumption: 0 1 2 3 4 5 6 7 8 9 10 9. On a scale of 0 – 10 rate your level of weekly recreational drug use: 0 1 2 3 4 5 6 7 8 9 10 10. Are you currently in a romantic relationship? Yes No On a scale of 1-10, how satisfied are you in this relationship: (ten being most satisfied) 1 2 3 4 5 6 7 8 9 10 11. What significant life changes or stressful events have you experienced?FAMILY MENTAL HEALTH HISTORY:In the section below identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (father, grandmother, uncle, etc.).Alcohol/Substance Abuse Yes No List Family MemberAnxiety Yes No List Family MemberDepression Yes No List Family MemberDomestic Violence Yes No List Family MemberEating Disorders Yes No List Family MemberObesity Yes No List Family MemberObsessive Compulsive Behavior Yes No List Family MemberSchizophrenia Yes No List Family MemberSuicide Attempts Yes No List Family MemberChronic Illness Yes No List Family MemberADDITIONAL INFORMATION:1. Describe the type of work do you:Do you enjoy your work?On a scale of 0 – 10 rate your level of stress at work: 0 1 2 3 4 5 6 7 8 9 10 2. Do you consider yourself to be spiritual or religious? No Yes 3. Would you like to include prayer in your therapy sessions? No Yes 4. Please list your strengths:5. Please list your weaknesses:What would you like to accomplish in therapy?What are you prepared to do to accomplish your therapy goal?Education: GED Diploma BA/BS MA/MS Ph.D. Other OtherAre you currently a student? No Yes What grade are you in currently?On a scale of 1 – 10 rate your level of learning success: (ten being highly successful) 1 2 3 4 5 6 7 8 9 10 On a scale of 1 -10 rate your level of classroom behavior (ten being most successful) 1 2 3 4 5 6 7 8 9 10 On a scale of 1 -10 rate your comfort with your peers: 1 2 3 4 5 6 7 8 9 10 On a scale of 1-10 rate your level of comfort with your family: 1 2 3 4 5 6 7 8 9 10 Is there anything else you would like me to know?Thank YouSharonCAPTCHA Δ
