COUNSELING CLIENT INTAKE FORM

Disclaimer: Thank you for your interest in being a client of .

Information collected about new clients is confidential and will be treated accordingly.

PATIENT DETAILS

Name: _____________________ Gender: ☐ Male ☐ Female ☐ Other

Street Address: __________________________________________

City: _____________________ State: _____________________ Zip Code: ________

E-Mail: _____________________ Phone: _____________________

Date of Birth: ____/____/____

Ethnicity/Race: _____________________

Education: ☐ GED ☐ High School ☐ Bachelor’s ☐ Master’s ☐ Ph.D.

RELIGION

Do you currently practice a religion? ☐ Yes ☐ No

-If yes, what is your faith? _____________________

EMERGENCY CONTACT

Emergency Contact Name: _____________________

Relationship: _____________________

E-Mail: _____________________ Phone: _____________________

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 RELATIONSHIP STATUS

Marital Status: ☐ Single ☐ Married ☐ Divorced ☐ Widowed

Length of Current Relationship: _____________________

Assessment of Current Relationship: ☐ Poor ☐ Fair ☐ Good ☐ Great

Number of Marriages: ____

EMPLOYMENT

Are you currently employed? ☐ Yes ☐ No

Employer’s Name: _____________________ Occupation: _____________________

Pay: $____________ per year (approx.)

Street Address: __________________________________________

City: _____________________ State: _____________________ Zip Code: ________

Phone: _____________________

MILITARY HISTORY

Military Experience? ☐ Yes ☐ No Combat Experience? ☐ Yes ☐ No

Branch: _____________________ Length of Service: _____________________

Type of Discharge: _____________________ Rank: _____________________

HOUSEHOLD AND FAMILY

List your current immediate family:

Name: _____________________ Relationship: _____________________ Age: ____

-Living with you? ☐ Yes ☐ No

Name: _____________________ Relationship: _____________________ Age: ____

-Living with you? ☐ Yes ☐ No

Name: _____________________ Relationship: _____________________ Age: ____

-Living with you? ☐ Yes ☐ No

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Name: _____________________ Relationship: _____________________ Age: ____
-Living with you? ☐ Yes ☐ No

Name: _____________________ Relationship: _____________________ Age: ____

-Living with you? ☐ Yes ☐ No

MEDICAL INFORMATION

Primary Care Physician: _____________________ Phone: _____________________

Street Address: __________________________________________

City: _____________________ State: _____________________ Zip Code: ________

List any current medical problems: _________________________________________

List any current medications: _________________________________________

List any current allergies: _________________________________________

Have you taken medication for a mental health concern? ☐ Yes ☐ No

Medication Name: _____________________ Dates: _____________________

-Was it helpful? ☐ Yes ☐ No

Medication Name: _____________________ Dates: _____________________

-Was it helpful? ☐ Yes ☐ No

Medication Name: _____________________ Dates: _____________________

-Was it helpful? ☐ Yes ☐ No

MEDICAL INSURANCE

Primary Insurance Company: _____________________

Policy Holder’s Name: _____________________ Group #: _____________________

ID #: ______________ Type: ☐ HMO ☐ PPO ☐ Medicare ☐ Other: ______________

PREVIOUS COUNSELING

Have you previously seen a counselor? ☐ Yes ☐ No

-If yes, who and where: ________________________________________

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Approximate dates of counseling: ________________________________________

Reason for counseling: ________________________________________

Do you have a previous mental health diagnosis? ☐ Yes ☐ No

-If yes, describe: ________________________________________

What did you find most helpful in therapy? ___________________________________

What did you find least helpful in therapy? ___________________________________

Have you used psychiatric services before? ☐ Yes ☐ No

ALCOHOL & DRUG USE

Do you currently consume alcohol? ☐ Yes ☐ No

• How often? ☐ Daily ☐ Weekly ☐ Occasionally ☐ Rarely
• How many drinks? ____ drink(s)

Do you currently smoke? ☐ Yes ☐ No

• What do you smoke? ☐ Tobacco ☐ Marijuana ☐ Other: ___________________

Do you currently use any other drugs? ☐ Yes ☐ No

• What other drugs do you take? _______________________________________
• How often? ☐ Daily ☐ Weekly ☐ Occasionally ☐ Rarely

Have you ever received treatment for alcohol or drug use? ☐ Yes ☐ No
• Where did you go? _________________________________________
• ☐ Inpatient ☐ Outpatient

Have you ever felt the need to cut down on your drinking/drug use? ☐ Yes ☐ No

Have you ever had other people criticize your drinking or drug use? ☐ Yes ☐ No

Have you ever felt bad or guilty about drinking or drug use? ☐ Yes ☐ No

Have you ever had a drink or used drugs first thing in the morning? ☐ Yes ☐ No

CURRENT ISSUES

What are the main issues for which you are seeking counseling?
______________________________________________________________________

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When did these issues first start?
______________________________________________________________________

What results would you like to get from counseling?

______________________________________________________________________

What is the most concerning issue for you right now?

______________________________________________________________________

FAMILY CONCERNS

Please check ANY of the following family concerns you are experiencing:

☐ - Abuse / neglect ☐ - Inadequate housing / feeling unsafe

☐ - Arguing ☐ - Infidelity
☐ - Alcohol abuse ☐ - Feeling distant
☐ - Birth of a family member ☐ - Job change
☐ - Death of a family member ☐ - Job dissatisfaction
☐ - Divorce / separation ☐ - Loss of fun
☐ - Drug abuse ☐ - Lack of honesty
☐ - Education problems ☐ - Lack of intimacy
☐ - Financial problems ☐ - Marriage issues
☐ - Inadequate health insurance ☐ - Physical fighting

List any other family concerns: __________________________________________

PERSONAL CONCERNS

Please select the severity of EACH of the following concerns:

• Alcohol abuse - ☐ None ☐ Mild ☐ Moderate ☐ Severe

• Anger issues - ☐ None ☐ Mild ☐ Moderate ☐ Severe
• Anorexia - ☐ None ☐ Mild ☐ Moderate ☐ Severe
• Anti-social behavior - ☐ None ☐ Mild ☐ Moderate ☐ Severe
• Anxiety / paranoia - ☐ None ☐ Mild ☐ Moderate ☐ Severe
• Appetite changes - ☐ None ☐ Mild ☐ Moderate ☐ Severe
• Bi-polar behavior - ☐ None ☐ Mild ☐ Moderate ☐ Severe
• Binging / purging - ☐ None ☐ Mild ☐ Moderate ☐ Severe
• Crying - ☐ None ☐ Mild ☐ Moderate ☐ Severe
• Decreased sex drive - ☐ None ☐ Mild ☐ Moderate ☐ Severe
• Drug abuse - ☐ None ☐ Mild ☐ Moderate ☐ Severe

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 • Excessive worrying - ☐ None ☐ Mild ☐ Moderate ☐ Severe
• Fear of death - ☐ None ☐ Mild ☐ Moderate ☐ Severe
• Headaches / migraines - ☐ None ☐ Mild ☐ Moderate ☐ Severe
• Hopelessness - ☐ None ☐ Mild ☐ Moderate ☐ Severe
• Hyperactivity - ☐ None ☐ Mild ☐ Moderate ☐ Severe
• Impulsivity - ☐ None ☐ Mild ☐ Moderate ☐ Severe
• Inability to focus - ☐ None ☐ Mild ☐ Moderate ☐ Severe
• Indecisiveness - ☐ None ☐ Mild ☐ Moderate ☐ Severe
• Low energy - ☐ None ☐ Mild ☐ Moderate ☐ Severe
• Low self-worth - ☐ None ☐ Mild ☐ Moderate ☐ Severe
• Nausea / indigestion - ☐ None ☐ Mild ☐ Moderate ☐ Severe
• Nightmares - ☐ None ☐ Mild ☐ Moderate ☐ Severe
• Panic attacks - ☐ None ☐ Mild ☐ Moderate ☐ Severe
• Poor concentration - ☐ None ☐ Mild ☐ Moderate ☐ Severe
• Problems at home - ☐ None ☐ Mild ☐ Moderate ☐ Severe
• Racing thoughts - ☐ None ☐ Mild ☐ Moderate ☐ Severe
• Restlessness - ☐ None ☐ Mild ☐ Moderate ☐ Severe
• Sadness - ☐ None ☐ Mild ☐ Moderate ☐ Severe
• Self-mutilation - ☐ None ☐ Mild ☐ Moderate ☐ Severe
• Sleep deprivation - ☐ None ☐ Mild ☐ Moderate ☐ Severe
• Spiritual concerns - ☐ None ☐ Mild ☐ Moderate ☐ Severe
• Suicidal thoughts - ☐ None ☐ Mild ☐ Moderate ☐ Severe
• Trauma flashbacks - ☐ None ☐ Mild ☐ Moderate ☐ Severe
• Unresolved guilt - ☐ None ☐ Mild ☐ Moderate ☐ Severe
• Weight (over or under) - ☐ None ☐ Mild ☐ Moderate ☐ Severe
• Work issues - ☐ None ☐ Mild ☐ Moderate ☐ Severe
• Workaholic (working too much) - ☐ None ☐ Mild ☐ Moderate ☐ Severe

List any other concerns: __________________________________________

SIGNATURE

Signature: ______________________ Date: ______________________

Print Name: ______________________

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