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
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Preferred Method of Contact
E-mail
Home Phone
Cell Phone
Employment
Please Select
Employed
Unemployed
Disabled
Retired
Student
Marriage & Family Information
Marital Status
Please Select
Single
Married
Divorced
Widowed
Spouse Name
First Name
Last Name
# of Years Married
Spouse's Education
Please Select
High School
GED
Bachelors
Post-graduate
Spouse's Employment
Please Select
Employed
Unemployed
Disabled
Retired
Student
Number of Children
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
Other
Do you use tobacco?
No
Daily
Weekly
Less
Former User
Do you use alcohol?
No
Daily
Weekly
Less
Former User
Caffeine use?
No
Daily
Weekly
Less
Former User
Are you currently taking prescription medication?
Yes
No
Please specify:
Family history
Adopted
Alcoholism
Allergies
Asthma
ArthritisBlood Disease
CAD (Heart Attack)
Cancer
CVA (Stroke)
Depression
Developmental Delay
Diabetes
Eczema
Hearing Deficiency
Hyperlipidemia (High Cholesterol)
Hypertension (High Blood Pressure)
Irritable Bowel Disease
Learning Disability
Mental Illness
Tuberculosis
Obesity
Osteoarthritis
Osteoporosis
PVD
Renal Disease
Other
Mental Health History
Please describe the issues with which you are struggling?
How do you hope counseling might help? (What are your expectations in coming here?)
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
Religious Background
Do you currently attend church regularly
Yes
No
Are you a member of Fruit Cove Baptist Church
Yes
No
Decline
Briefly explain your religious background
Explain any recent changes in your religious/spiritual life, if any
*Your signature below indicates that the information you have provided above is truthful.
Date
-
Month
-
Day
Year
Date
Signature
*
Submit
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