Adult Intake Form

Family & Home Life
Mother Living (age)
Mother Deceased (date)

Month Day Year
Date
Father Living (age)
Father Deceased (date)

Month Day Year
Date
How many Siblings do You have?
I am the:

Oldest In the Middle Youngest Only Child
Names and ages of your children
Names and ages of step children
Who lives at home with you?
Please list all occupants, excluding yourself.
Have you or anyone in your family ever experienced domestic violence or abuse?

Yes No
If yes, please explain:
Are you currently experiencing domestic violence or abuse?

Yes N
Religion/Denominational Preference:
Church:

Mental Health History
Have you experienced mental health problems before?

Yes No
If yes, please explain:
Do you have a family history of mental health issues?

Yes No
Have you ever received outpatient treatment (counseling, therapy, psychiatrist) for mental health issues?

Yes No
If yes, when and where?
Have you ever been hospitalized or received inpatient treatment for mental health issues?

Yes No
If yes, when and where?

Acknowledgment
The information written on this form is accurate, to the best of my knowledge.
Signature of Client *

Clear
Date

Month Day Year
Date

Appointment Reminder Preference
New Hope Counseling Center utilizes a contracted text service to provide automated reminders of your next appointment 24 – 48 hours in advance as a courtesy reminder.
Yes, I would appreciate a text reminder. Please text me prior to my appointment. I understand that if others have access to this number, confidentiality cannot be ensured. No, I would prefer not to be reminded of appointments and will keep up with them myself
If yes, please provide your preferred phone number:
Client Name:
Signature of Client *

Clear
Date

Month Day Year
Date

No-Show & Cancellation Policies
When you schedule an appointment with our staff, New Hope Counseling Center reserves that time just for you. If you are not going to attend your scheduled appointment, we would like to give another client the opportunity to take that opening. It affects our funding, our ability to budget our staff, and staff salaries when there are missed appointments. That is why we require 24-hour advance notification of cancellation. Leaving a message on our voicemail is fine, even on weekends. The time you called will be posted with the message. If you fail to give 24-hour notice before cancelling your appointment or do not show for your appointment up to two times, your therapist has the right to refuse services or you may be asked to make your appointment two to three weeks from missed appointment date. We appreciate the courtesy you extend to us by honoring this agreement. Please note that we cannot bill your insurance company for missed sessions or for late cancellations.

Weather Related: Missed appointments due to dangerous weather will not count as a late cancellation.

Due to the counselors maintaining a set schedule:
- I f you a r e 30 m inu tes l ate f o r 6 0 - m i n u te a p p o i ntm e nt, y o u will be able to be seen for 30 minutes .
By signing this agreement I acknowledge my understanding of all the policies listed above. I accept and agree to all of the above terms during the course of my treatment at New Hope Counseling Center.
Client Name:
Signature of Client *

Clear
Date

Month Day Year
Date

Informed Consent for Psychotherapy/Counseling, & Receipt of Privacy Practices
I have been provided with a printed copy of the Explanation of Psychotherapy/Counseling Services and Notice of Privacy Practices packet. In addition, the therapist/counselor/clinical social worker has provided a verbal explanation of psychotherapy/counseling/clinical social work services and privacy practices, to include exceptions to confidentiality. I have been afforded an opportunity to review the Explanation of Psychotherapy/Counseling Services and Notice of Privacy Practices packet, other pertinent information, and to ask questions. All questions have been answered to my satisfaction.

I am making an informed decision, free of any coercion, to engage in psychotherapeutic/counseling/clinical social work services. It is my right to terminate these services at any point.
Client Name:
Signature of Client *

Clear
Date

Month Day Year
Date
Should be Empty:

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Adult Intake Form

Military

Employment

Family & Home Life

Medical History

Mental Health History

Self Harm

Substance Use History

Acknowledgment

Appointment Reminder Preference

No-Show & Cancellation Policies

Informed Consent for Psychotherapy/Counseling, & Receipt of Privacy Practices