Counseling Intake Form

Counseling Intake Form
Patient Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Email
example@example.com
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
E-mailHome PhoneCell Phone
Employment
How did you hear about us?
Marriage & Family Information
Marital Status
Number of children and ages
Name of Spouse/Significant Other

First NameLast Name
Age
Email
example@example.com
Phone Number

Area CodePhone Number
YesNoOther

List days/times for your appointment availability (please click all that apply)

Rows	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday
Morning
Afternoon
Evening

OnlineIn PersonBothOther
What type of counseling are you seeking? (please select one)
Medical History
NoneAllergiesAnemiaAnginaAnxietyArthritisAsthmaAtrial FibrillationBenign ProstaticHypertrophyBlood ClotsCancerCerebrovascular AccidentCronary Artery DiseaseCOPD (Emphysema)Crohn's DiseaseDepressionDiabetesGallbladder DiseaseGERD (Reflux)Hepatitis CHyperlipidemiaHypertensionIrritable Bowel DiseaseLiver DiseaseMigraine HeadachesMyocardial InfarctionOsteoarthritisOsteoporosisPeptic Ulcer DiseaseRenal DiseaseSeizure DisorderThyroid DiseaseOther
NoDailyWeeklyFormer User
NoDailyWeeklyFormer User
If yes, please specify which drugs
YesNo
Please explain the circumstances
YesNo
If yes, please specify which medications
Mental Health History
Why are you are seeking treatment?
HomeWorkMarriageOther RelationshipsGod
How long has this been going on?
MildModerateSevereTotally Incapacitating
Abuse (Physical)Abuse (Sexual)Abuse (Verbal)Abuse in the PastAddictionAngerAnxietyApathyBad MemoriesBitternessBlackouts/Memory LossCaring for ParentsChronic PainCommunication IssuesCompulsionsConflict ResolutionCrying SpellsDepressionDebtDeathDelusionsDiscontentmentDivorceDoubt SalvationEating DisorderEmpty NestEnvyFamily ConflictFearFinancial ManagementForgivenessGreedGriefGuiltHallucinationsHealth ConcernsHearing VoicesHumiiltyIdentityImpatienceInfertilityInsecurityInsomniaJealousyJudgmentalLifestyle ChangeLonelinessLoss of AppetiteLoss of InterestLyingManipulationMarital IntimacyMoodinessNightmaresObsessive CompusivePanic AttacksParanoiaParentingPeer PressurePeople PleasingPerfectionismPornographyPridePrioritiesProcrastinationPurpose (Lack Of)Racing ThoughtsRebellionRegretsRejectionRelationshipsRespectSame Sex AttractionSchoolSelf ControlSelfishSexual SinShameSocial AnxietySpiritual GrowthSubmissionSuicidal ThoughtsTime ManagementTiredTrustWorkOther
What do you expect from this counseling?
YesNo
Therapist Name

First NameLast 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 accurate and truthful.
Date

MonthDayYear
Date
Signature

Clear
Please verify that you are human*
Should be Empty:

Counseling Intake Form

Marriage & Family Information

Medical History

Mental Health History