Counseling Intake Form

Counseling Intake Form
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
Cell Phone
Preferred Method of Contact

E-mail Home Phone Cell Phone
Employment
How did you hear about us?
Marriage & Family Information
Marital Status
Number of children and ages
Name of Spouse/Significant Other

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

Area Code Phone Number
Is the spouse/significant other willing to come to counseling?

Yes No

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

I would prefer counseling to be:

Online In Person Both
What type of counseling are you seeking? (please select one)
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
Do you use alcohol?

No Daily Weekly Former User
Do you use drugs?

No Daily Weekly Former User
If yes, please specify which drugs
Have you been convicted of drug related charges?

Yes No
Please explain the circumstances
Are you currently taking prescription medication?

Yes No
If yes, please specify which medications
Mental Health History
Why are you are seeking treatment?
Where are your concerns causing problems for you? (select all that apply)

Home Work Marriage Other Relationships God
How long has this been going on?
Please rate the severity of your present concerns.

Mild Moderate Severe Totally Incapacitating
Please indicate which of the following areas are currently problems for you. (check all that apply)

Abuse (Physical) Abuse (Sexual) Abuse (Verbal) Abuse in the Past Addiction Anger Anxiety Apathy Bad Memories Bitterness Blackouts/Memory Loss Caring for Parents Chronic Pain Communication Issues Compulsions Conflict Resolution Crying Spells Depression Debt Death Delusions Discontentment Divorce Doubt Salvation Eating Disorder Empty Nest Envy Family Conflict Fear Financial Management Forgiveness Greed Grief Guilt Hallucinations Health Concerns Hearing Voices Humiilty Identity Impatience Infertility Insecurity Insomnia Jealousy Judgmental Lifestyle Change Loneliness Loss of Appetite Loss of Interest Lying Manipulation Marital Intimacy Moodiness Nightmares Obsessive Compusive Panic Attacks Paranoia Parenting Peer Pressure People Pleasing Perfectionism Pornography Pride Priorities Procrastination Purpose (Lack Of) Racing Thoughts Rebellion Regrets Rejection Relationships Respect Same Sex Attraction School Self Control Selfish Sexual Sin Shame Social Anxiety Spiritual Growth Submission Suicidal Thoughts Time Management Tired Trust Work
What do you expect from this counseling?
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 accurate and truthful.
Date

Month Day Year
Date
Should be Empty:

	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday
Morning
Afternoon
Evening

Counseling Intake Form

Marriage & Family Information

Medical History

Mental Health History