Initial Intake Form

Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Age*

Email

example@example.com

Address

Street Address

Street Address Line 2

Postal / Zip Code

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Date of Birth*

Date

Religion

MaleFemaleOther

Ethnicity

Nationality

Occupation

Company Name

Emergency Contact Person

First NameLast Name

Relationship to the patient

Primary Phone Number of Emergency Contact Person

Please enter a valid phone number.

Secondary Phone Number of Emergency Contact Person

Please enter a valid phone number.

Weight

Height

What issues or problems are you currently experiencing?*

What would you like to be the outcome of the counseling sessions?

YesNo

If yes, please state the reason and when.

Please select the following symptoms you are experiencing

Rows	Mild	Moderate	Severe
Aggression
Agitation
Anger
Anxiety
Appetite change
Change in libido
Compulsions
Crying/tearful
Cyber addiction
Delusions
Depression
Disorientation
Difficulty getting out of bed
Difficulty making decisions
Distractibility
Eating disorder
Judgment errors
Loneliness
Loss of interest in activities
Physical trauma perpetrator

YesNo

If yes, please tell me the medication name, purpose, and the frequency.

YesNo

If yes, please tell me more about it.

If you're experiencing any non-psychiatric medical conditions, please list them below so that I am aware of it.

YesNo

If you have history of drinking alcohol, please explain below how often do you do it?

If you have history of taking illegal substance, kindly elaborate below.

YesNo

Patient's Signature*

Non Disclosure Agreement

All interactions which take place in the setting of therapy are considered confidential. This includes requests by telephone, all interactions with this counselor, any scheduling or appointment notes, all session content records and any progress notes that I take during your sessions. I will not even verify that you are a client. You may choose to give me permission in writing to release any or specific information about you to any person or agency that you designate.

Limits to this agreement
In some legal proceedings a judge may issue a court order. This would require this counselor to testify in court.
If I learn of or believe that there is physical or sexual abuse or neglect of any person under 18 years of age, I must report this information.
If I learn of or believe that an elderly person, or disabled person is being abused or neglected, I must file a report with the appropriate state agency that handles elder abuse.
If I learn of or believe that you are threatening serious harm to another person, I am obligated to report this. This can be in the form of telling the person who you have threatened, contacting the police or placing you into hospitalization.
If there is evidence that you are a danger to yourself and I believe that you are likely to kill yourself unless protective measure are taken, I may be obligated to seek hospitalization for you or to contact family members or others who can help provide protection.
There may be times when I consult with outside sources about cases. In these cases, no personally identifiable information will be used to discuss this case. However, discussion topics will be used in order to ensure that I am getting and giving the best assistance possible. The persons with whom I discuss cases are legally bound to keep information confidential.
 

I have read and discussed the above information with my therapist. I understand the nature and limits of confidentiality.

Date Signed

Date