704-806-4606
sharon@integratedtherapiesnc.com
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Personal Counseling
– Common Therapies
Mental Health in the Workplace
Reviews
Resources
– Blog
– Free Resource
– Podcast
– Programs
– Psychological Effects of Color
– Videos
– Recommended Readings
Contact
– Patient Forms
Client Intake Form
Counseling Intake Form
Please 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 INFORMATION
1. 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 Member
Anxiety
Yes
No
List Family Member
Depression
Yes
No
List Family Member
Domestic Violence
Yes
No
List Family Member
Eating Disorders
Yes
No
List Family Member
Obesity
Yes
No
List Family Member
Obsessive Compulsive Behavior
Yes
No
List Family Member
Schizophrenia
Yes
No
List Family Member
Suicide Attempts
Yes
No
List Family Member
Chronic Illness
Yes
No
List Family Member
ADDITIONAL 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
Other
Are 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 You
Sharon
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