Counseling Intake Form
Buttafleye Ministry, Kingdom Kounseling
Patient Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Home Phone
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Preferred Method of Contact
E-mail
Home Phone
Cell Phone
Marital Status
Please Select
Single
Married
Divorced
Widowed
Do you live with your family?
Yes
No
Do you have children
Yes
No
Yes, don't live with me
Yes, don't know the child(ren)
Are you in an Abusive relationship?
Yes
No
I'm in danger
Employment
Please Select
Employed
Unemployed
Disabled
Retired
Student
Are you unemployed
Yes
No
Primary Care Provider
Referral Name
First Name
Last Name
Are you homeless?
Yes
No
Living from couch to couch
Emergency Contact Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Relationship
Medical History
Please check all the apply
None
Allergies
Anemia
Angina
Anxiety
Arthritis
Asthma
Atrial Fibrillation
Benign Prostatic
Hypertrophy
Blood Clots
Cancer
Cerebrovascular Accident
Cronary Artery Disease
COPD (Emphysema)
Crohn's Disease
Depression
Diabetes
Gallbladder Disease
GERD (Reflux)
Hepatitis C
Hyperlipidemia
Hypertension
Irritable Bowel Disease
Liver Disease
Migraine Headaches
Myocardial Infarction
Osteoarthritis
Osteoporosis
Peptic Ulcer Disease
Renal Disease
Seizure Disorder
Thyroid Disease
Other
Do you use tobacco?
No
Daily
Weekly
Less
Former User
Do you use alcohol?
No
Daily
Weekly
Less
Former User
Caffeine use?
No
Daily
Weekly
Less
Former User
Have you been convicted of drug related charges?
Yes
No
Please explain the circumstances
Are you currently taking prescription medication?
Yes
No
Prescribing Doctor's Name
First Name
Last Name
Prescribing Doctor's Phone
-
Area Code
Phone Number
Have you had any surgeries in the past 5 years?
Yes
No
Please specify:
Family history
Adopted
Alcoholism
Allergies
Asthma
ArthritisBlood Disease
CAD (Heart Attack)
Cancer
CVA (Stroke)
Depression
Developmental Delay
Diabetes
Eczema
Hearing Deficiency
Hyperlipidemia (High Cholesterol)
Hypertension (High Blood Pressure)
Irritable Bowel Disease
Learning Disability
Mental Illness
Tuberculosis
Obesity
Osteoarthritis
Osteoporosis
PVD
Renal Disease
Other
Mental Health History
Why you are seeking treatment?
What do you expect from this counselling?
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?
Yes
No
Therapist Name
First Name
Last Name
Reason for seeking help
Average hours of sleep per night
Please describe any other experiences you have had problems with
Additional comments or concerns
*Your signature below indicates that the information you have provided above is truthful.
Date
-
Month
-
Day
Year
Date
Signature
Submit
Should be Empty: