Clinical Intake Form

Clinical Intake Form
Basic Information
Name*

First Name Last Name
Address*

Street Address
Street Address Line 2
City State
Zip Code
Phone Number

Area Code Phone Number
Date of Birth*

Month Day Year
Age*
Work History
Are you currently employed?

Yes, if so please complete employment related questionsNo, if not, please continue to Education
Current Occupation
Employer
Work schedule

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Work Hours

:Hour Minutes AM/PM Option
Until
until :Hour Minutes AM/PM Option
How satisfied are you with your job?

Not at allSomewhat satisfiedVery satisfied
Education
Highest grade completed

123456789101112
College degrees

AssociatesBABSMAMSPhD
Major/area of specialization
What do you like to do in your free time?
Marital Status*

SingleMarriedWidowedSeparatedDivorcedCohabitingOther
Current partner's name
Together Since
Marital History or Long Term Relationship (LTR)
1st marriage or LTR

First Name Last Name
Length of marriage or LTR
2nd marriage or LTR

First Name Last Name
Length of marriage or LTR
3rd marriage or LTR

First Name Last Name
Length of marriage or LTR
Have you experienced any of these things in your marriage or LTR

InfidelityAddictionsDeath of a spouseDeath / loss of a childEmotional abuseVerbal AbusePhysical AbuseFinancial problems
Health
Major health conditions
Minor health conditions
Primary Physician*

First Name Last Name
Clinic*
Psychiatrist

First Name Last Name
Clinic
Medications
Additional medications and supplements
Special health requirements
Other health treatments/services that you utilize
Exercise
Do you Exercise

YesNoOccasional
If so, what form of exercise and how frequent?
Household members
Children living in your household FULL time
Children living in your household PART-TIME or visiting with you regularly
Are there any special concerns about any of your children that it is important to mention?
Are there any other relatives or friends living in your household?
Mental health history
Have you ever been in therapy before?

YesNo
If so, what month and year
How long were you in therapy?
Reason for therapy
Have you ever been hospitalized for a mental health condition?

YesNo
If so, what month and year
Name of hospital
Location
How long did you stay?
Have you ever attempted suicide?*

YesNo
If so, what month and year
Are you currently having suicidal thoughts?*

YesNo
Family mental health history
Do any of your family members (going back to your grandparents, aunts & uncles, cousins) have a mental health condition?

YesNo
Relative name
Mental health diagnosis
Relative name
Mental health diagnosis
Please check the things that are causing you the most difficulty

AssertivenessParentingBowelsNightmaresBedwettingNervousnessPhysical abuseEducationTemperStressMemoryHeadachesUnhappinessPremaritalIn-lawsHealth problemsAlcohol useSexual problemsLonelinessUlcerssEnergyChildrenDivorceDepressionInferiorityDrug useFinancesFearsFoodMy pastCareer choicesLegal mattersMarriageConcentrationMy thoughtsSleepParentsRelaxationSexual abuseFriendsMuscle tensionAppetiteWorkSelf-controlGuiltStomach problemsReligionSeparationSuicidal thoughtsDecision makingInsomniaAmbitionShynessDatingTirednessSchoolConfusionSadnessOther
Briefly describe your reasons for seeking professional help at this time
What would you like to accomplish through therapy?
Privacy & Confidentiality

Hope Counseling Inc respects your privacy and ensures your information is kept private and confidential in accordance with HIPPA policies and guidelines.
Should be Empty:

Clinical Intake Form

Basic Information

Work History

Education

Marital History or Long Term Relationship (LTR)

Health

Medications

Exercise

Household members

Mental health history

Family mental health history