Abiding Hope Adult Intake

ADULT INTAKE FORM
TODAY'S DATE

Month Day Year
Date
Home Phone
Please enter a valid phone number.
Client Name
Cell Phone Number
Please enter a valid phone number.
Street Address
Date of Birth
City, State, Zip Code
Marital Status:

Single Married Divorced Widowed
Email
example@example.com
Referred By:
Are you comfortable with the therapist praying at the end of each session?
Briefly list the reason for your visit?
Are you currently feeling suicidal?
If so, do you have a plan?
Have you recently been hospitalized for suicidal ideations?
Has anyone in your family completed suicide? If YES, who and when:
Do you cut or do any other self-harm behaviors?
Have you ever been under the care of a psychiatrist or therapist?

Yes No
If yes, with whom and what was the nature of the treatment?
Are you currently under the care of a psychiatrist or therapist?

Yes No
If yes, with whom and what is the nature of the treatment?
Have you received any psychological testing?
Do you currently have a physician?
(If so, complete authorization form on page 10)
Do you use alcohol or other drugs on a regular basis and if so, how often?

How would you describe your present PHYSICAL health? (Excellent, good, fair, poor)
How would you describe your present EMOTIONAL health? (Excellent, good, fair, poor)
How would you describe your present SPIRITUAL health? (Excellent, good, fair, poor)
Other symptoms not mentioned above:
Marriage:
Currently Married?

Married Divorced Single
Spouse: blanks Age: blank Year Married: How many pregnancies: How many live births: Loss due to:
Were pregnancies natural or was IVF used?
Children: (list names and ages):
Describe your marriage briefly
Any previous marriages by you or your spouse?
Has there ever been an infidelity?
Issues with pornography?
Are you currently sexually active?
Finances
Current occupation?
Have you recently lost a job?
Have you ever lost a job or business?
Any financial problems at present?
Have you ever been arrested?
Current legal problems?
Military service?
Childhood
Names of parents & siblings:
Are they living?
Is there any family history of mental or emotional illness?
Briefly describe what it was like growing up in your home
Describe discipline used in your home/who enforced it.
Was mother’s pregnancy (with you) & delivery normal? Any complications? Were all developmental milestones (walking, talking, and toilet training) met at normal times? Normal childhood diseases?
Any hospitalizations, trauma (including sexual or physical abuse) while growing up?
Any outstanding memories (positive or negative) regarding elementary, middle, or high school?
Highest grade completed
Any learning disabilities?
What are your ambitions/goals?

What do you consider your greatest assets/strengths/talents/capabilities?
What do you consider your weaknesses?
What have the three greatest obstacles in life been?
Do you have any hobbies or interests?
How is most of your free time occupied?
Does your present way of life and work satisfy you?
In what way of life/work do you think you would be happiest?
Who are your current friends?
What is the role of religion/spirituality/church in your life, both past and present?
Denomination?
Anything else that I should know?

AUTHORIZATION FOR RELEASE OF MENTAL HEALTH INFORMATION
I hereby authorize Ginger Gray, LCSW and Abiding Hope Christian Counseling, to disclose the individually identifiable health information as described below, which may include psychotherapy notes. I understand that if I do not sign this form, federal and state law will prohibit Ms. Gray and her practice from releasing records regarding her treatment of me/my child to the designated Recipient. By accepting the records pursuant to this Authorization, the Recipient acknowledges that the protected health information covered by this release is confidential, privileged and protected by federal and state privacy statutes and regulations, and agrees that Ms. Gray’s release of the individually identifiable health information will continue to be protected by federal and state privacy statutes and regulations.
Social Security Number
Date(s) of service (if known)
When did you receive services from Abiding Hope Christian Counseling
Description of information to be released: (check all that apply)

Entire Record Billing Record Psychotherapy Notes Evaluation Reports Consultation Notes Other
Description of the purpose of the use and/or disclosure:
NAME AND ADDRESS OF DESIGNATED RECIPIENT
I intend for this Authorization to remain in full force and effect until I revoke it in writing. Further, it is my intent that a copy of this Authorization shall have the same effect as the original. I further understand that I may revoke this authorization at any time by notifying Ginger Gray, LCSW in writing at Abiding Hope Christian Counseling, 19115 FM 2252, Suite 12, San Antonio, TX 78266. I also understand that the written revocation must be signed and dated with a date that is later than the date on this authorization. The revocation will not affect any actions taken before the receipt of the written revocation
Signature

Clear
Date

Month Day Year
Date
Relationship to Client
Should be Empty:

ADULT INTAKE FORM

BRIEF MAST

Select any of the following that apply to you:

Marriage:

Finances

Childhood

AUTHORIZATION FOR RELEASE OF MENTAL HEALTH INFORMATION