Adult Intake Form (ALCS)

ALCS Adult Intake Form

Thank you for choosing Abundant Life Counseling Services, P.A. So that we can better assist you, please fill out this form as fully and openly as possible. All information is held in strictest confidence within legal limits. If certain questions do not apply to you, you can leave them blank
Who is your ALCS counselor?
Identifying Information
Full Name

First NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Age
Race & Ethnicity
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Home Phone

Area CodePhone Number
May we call you at the phone number(s) provided above? Check all that apply.
May we leave you a voicemail at the phone number(s) provided above? Check all that apply.
Occupation
Religion / Spirituality
Email Address
example@example.com
May we email you at this email address?
How did you hear about us?
Current Marital Information

If you are currently married, please fill out the information below about your spouse.
My relationship status is...

Other
Name of Spouse

First NameLast Name
Date of Marriage

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Spouse's Address (if different from yours)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Home Phone

Area CodePhone Number
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Age
Race & Ethnicity
Occupation
Religion / Spirituality
Is your spouse willing to come in for counseling?
Have you ever separated from your current spouse?
When?
Have either of you filed for divorce?
When?
How old were you both when you got married?
How long did you know your spouse before marriage?
Length of steady dating with spouse?
Length of engagement?
Previous Marital History

Self

Rows	Name of Previous Spouse	Date of Marriage	Date of Divorce/Death
1
2
3
4

Spouse

Rows	Name of Previous Spouse	Date of Marriage	Date of Divorce/Death
1
2
3
4

Your highest level of education completed
Degree(s)
Have you had any coursework related to Mental Health or Psychology? If yes, describe briefly:
Your spouse's highest level of education completed
Degree(s)
Has your spouse had any coursework related to Mental Health or Psychology? If yes, describe briefly:

Children

Rows	Child's Name	Age	Gender	Father's / Mother's First Name
1
2
3
4
5
6

Rows	Medication	Dosage	Frequency	Purpose	Physician
1
2
3
4
5
6

Rows	Substance	Amount	Frequency
1
2
3
4
5
6

Rows	Never	Rarely	Sometimes	Frequently
1. Life is hopeless.
2. I am lonely.
3. No one cares about me.
4. I am a failure.
5. Most people don't like me.
6. I want to die.
7. I want to hurt someone.
8. I am so stupid.
9. I am going crazy.
10. I can't concentrate.

Rows	Never	Rarely	Sometimes	Frequently
11. I am so depressed
12. God is disappointed.
13. I can't be forgiven.
14. Why am I so different?
15. I can't do anything right.
16. People hear my thoughts.
17. I have no emotions.
18. Someone is watching me.
19. I hear voices in my head.
20. I am out of control.

ALCS Adult Intake Form

Identifying Information

Current Marital Information

Previous Marital History

Personal Information

Health Information

For Women

Personal Concerns

Thoughts and Behaviors

Symptoms

Specific Personal Concerns

Emergency Contact