Client Intake Form

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
Name

First NameMiddle Initial or Maiden NameLast Name
Birth Date

MonthDayYear
Date
Gender

MaleFemale
Email
example@example.com
I give permission for my therapist and me to communicate through email

YesNo
Phone Number
Please enter a valid phone number.
Messages can be left at this number

YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Employment
How long?
Months & years at place of employment
Emergency Contact
First & Last Name
Phone Number
I waive any confidentiality rights in an emergency, and understand my therapist may contact this person; I agree to hold them harmless.

Personal Information
What primary issue brings you to counseling?
What recent event(s) prompted you to seek counseling?
What ongoing problem(s) has (have) contributed to you seeking counseling?
Describe any losses you have experienced in the past two years (family members, job, spouse, etc.)
What are your expectations in coming here?
List 3-5 words that describe you

Describe your usage (or abuse) of the following
Alcohol
Caffeine
Tobacco
Marijuana
Prescription medication
Have you ever used drugs for non-medical purposes?

YesNo
When did you last use drugs?
Have you ever had a severe mood alteration that resulted in prolonged cryuing, depression, or mania?

YesNo
When, for how long, and what caused it?
Please share anything else you believe may be helpful for you and your counselor

	# of times	Dates: __/__-__/__	Dates: __/__-__/__	Dates: __/__-__/__	Dates: __/__-__/__	Dates: __/__-__/__
Self
Spouse

	You	Family Member
Extreme Depressed Mood
Wild Mood Swings
Rapid Speech
Extreme Anxiety
Panic Attacks
Phobias
Sleep Disturbances
Hallucinations
Unexplained Losses of Time
Unexplained Memory Losses
Alcohol/Substance Abuse
Frequent Body Complaints
Eating Disorder
Body Image Problems
Repetitive Thoughts (e.g. Obsessions)
Repetitive Behaviors (e.g. Frequent Checking, Hand-washing)
Homicidal Thoughts
Suicide Attempt
Schizophrenia
Learning Disabilities
Trauma/Severe Abuse (Physical, Emotional/Verbal, Sexual)

Basic Information