• Ridgecrest
    6801 Wesley Street
    Greenville, Texas 75402
    903.455.0020
    www.ridgecrest.com
    Carolyn Scott, M.A., L.P.C.

  • Client Intake Form

    Please provide the following information for our records. Leave blank any question you would rather not answer. Information you provide here is held to the same standards of confidentiality as our therapy.

  • Basic Information

  • Birth Date
     - -
  • Gender
  • I give permission for my therapist and me to communicate through email
  • Format: (000) 000-0000.
  • Messages can be left at this number
  • Format: (000) 000-0000.

  • Marital Information

  • Current marital status
  • Spouse's Birth Date
     - -
  • Format: (000) 000-0000.
  • Rows
  • Rows

  • Spiritual Beliefs

  • Does your spouse and/or dependents share your beliefs/faith practice?
  • Do you consider your faith community a support system?
  • Are you opposed to my Christian-value system and its influence on my practice?

  • You do not have to be a Christian to receive counseling here. We take your personal beliefs very seriously and will always respect them. We want you to feel free to express your values and beliefs and how they affect the way you live. While we will always respect your beliefs we may encourage you to consider biblical truths that, if applied to your life, will help you live a more fulfilling, meaningful life. We may introduce ideas during our conversations that will encourage you to change how you are living in ways that will be enriching to you and those around you.

  • Personal Information

  • Health Information

  • How would you rate your health?
  • Do you sleep well?
  • Have you experienced significant weight changes recently?
  • Do you have eating problems (bingeing, overeating, purging, etc.)?

  • Describe your usage (or abuse) of the following

  • Have you ever used drugs for non-medical purposes?
  • Have you ever had a severe mood alteration that resulted in prolonged cryuing, depression, or mania?

  • Medical Information

  • Have you seen your physician in the last year?

  • Mental Health Information

  • Are you currently under the care of a mental health professional (psychiatrist, psychologist, counselor?
  • Have you ever received counseling or psychiatric care in the past?
  • Have you ever been given a mental health diagnosis by a mental health professional?
  • Do you believe the diagnosis was accurate?
  • Have you ever been hospitalized for mental health reasons?
  • Have you ever attempted suicide?
  • Do you have a history of self-injury? (cutting, burning, hitting, etc.)
  • Have you ever physically harmed another person?
  • Is there a history of suicide in your immediate or extended family?
  • Are you presently having thoughts of harming yourself or someone else?
  • Have you had any recent memory loss?

  • Symptom History

    Have you or anyone in your family experienced difficulties with any of the following? Check those that apply to you and list family member(s) who has (have) experienced it.
  • Rows
  • Date
     - -
  • Should be Empty: