1a. Intake Form (Adult)

Client # (office staff):
Agape Psychological Consortium

Intake Form (Adult)
Identifying Information:
Date completed Intake Form:

MonthDayYear
Client's Name*

First NameMiddle NameLast NameSuffix
SS#: for insurance purposes only
Date of Birth:*

MonthDayYear
Current Age:
Race:*
Primary language spoken in home:
MaleFemale
Relationship Status:
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone #:*
Secondary Phone #:
Email address:*
Legal guardianof adult client:

First NameLast Name
Relationship to client:
Agency:
Director (Out-of HOme Placement):

First NameLast Name
Facility/Program Name:
Primary Phone #:
Email address:
Reason(s) for seeking services at this time:
TherapyEvaluationConsultation
YesNo
If yes, when:
Family Information:
Family members/other significant relationships in client's life:
Psychiatric History:
YesNo
If yes, where/with whom:
YesNo
If yes, who:
YesNo
If yes, what:
YesNo
EmotionalPhysicalSexualDV
YesNo
If yes, why:
YesNo
If yes, what:
YesNo
If yes, what:
YesNo
If yes, what:
List any prescribed medications:
Educational History:
Last grade completed:*
YesNo
YesNo
Work/Military History:
YesNo
If yes, where & how long?
YesNo
If yes, branch of service:
If combat experience, where/when?:
Type of discharge:
Rank at discharge:
Legal Issues:
YesNo
Current status:
If legal problems, charges:
YesNo
Charges:
Special Considerations:
YesNo
YesNo
Alcohol/Substance Use History:
YesNo
YesNo
YesNo
If yes, what?
Lethality History:
YesNo
YesNo
YesNo
YesNo
Treatment Plan:
What things have you done so far to help with the current situation?
a.
b.
What goals would you want to work on in treatment?
a.
b.
Referral Information:
Name of referring person/doctor:
Name of referring program/office:
YesNo
Phone #:
Fax #:
Primary Care Physician:
Primary Care Physician:
Name of Practice:
Address location:
Phone #:
Fax #:
Emergency Contact:
Person to call in case of an emergency:
Phone #:
Authorization:
As legal guardian of this particular adult client, I have the legal authorization to give Agape Psychological Consortium permission to:
YesNo
YesNo
My typed initials acknowledges that I have read this Intake Form:*
Date signed:

MonthDayYear
My typed initials verify that I am the client/legal guardian listed on this document:*
Date signed:

MonthDayYear
Should be Empty:

Agape Psychological Consortium