Intake Form

Intake Form
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
What is your age? *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Email *
Work Number

Area Code Phone Number
Occupation
Who referred you?

In Case of Emergency
Name of Locale Friend or Relative (not living at the same address)

First Name Last Name
Relationship of Client
Phone Number

Area Code Phone Number
Work Phone Number

Area Code Phone Number
PLEASE READ THE FOLLOWING CAREFULLY
I understand that I am responsible for my fee payment at the beginning of each appointment. I agree to be responsible for full payment of fees for services rendered regardless of whether insurance reimbursement will be sought. Leslie Rouder, LCSW will honor contractual agreements made with those managed health care companies which stimulate specific reimbursement restrictions.

I hereby consent to treatment by Leslie Rouder, LCSW. Although the chances for obtaining my goals for therapy will best be met by adhering to therapeutic suggestions, I understand that I have the right to discontinue or refuse treatment at any time. I understand that I am responsible, however, for any balance due prior to a decision to stop.

I hereby authorize the release of necessary medical information for insurance reimbursement purposes.
Signature

Clear
Date

Month Day Year
Date

Marital History
Marital status:

Single/never married Married Separated Divorced Widowed Living with someone
If married, when were you married?
If living with someone, how long?

Please list your children:

	Names	Age	Relationship (biological/step)	Lives with
1
2
3
4
5

Level of Functioning
List or describe any current impediments or problems in daily psychological, social, or occupational functioning (i.e. isolation from friends/family, significant difficulty getting to work or completing tasks, sever financial strain, recent divorce, and problems with supervisor, etc.)

Please check any of the following that apply to you:

	Please check below that apply
I sometimes hear voices even though no one nearby is talking to me.
I sometimes feel that forces outside of me control me.
I sometimes feel that other people control my thoughts.
I sometimes have the same thought over and over and cannot control it.
I sometimes feel that someone is out to hurt me and do something against me.
I am sometimes unable to control my behavior.

Please explain:
Is there any other information regarding you or your family that you would like the share with your Therapist that is not covered on this form? You may also use this space to complete earlier responses.
Please list your therapy goals:

Signature
By signing below I consent that all information provided in this intake form has been answered to the best of my ability. This is a strictly confidential medical record. Redisclosure or transfer is expressly prohibited by law.
Name

First Name Last Name
Today's Date

Month Day Year
Date
Signature

Clear
Should be Empty:

	Medication/Supplement	Dosage	Start Date	Purpose
1
2
3
4
5

	Check all that apply	Notes
I have a no problem or concern bring me here
Abuse-physical, sexual, emotional, neglect (of children or elderly persons), cruelty to animals
Aggression, violence
Alcohol use
Anger, hostility, arguing, irritability
anxiety, nervousness
Attention, concentration, distractibility
Career concerns, goals, and choices
Childhood issues (your own childhood)
Codependence
Confusion
Compulsions
Custody of children
Decision making, indecision, mixed feelings, putting off decisions
Delusions (false ideas)
Dependence
Depression, low mood, sadness, crying
Divorce, separation
Drug use - prescription medications, over-the-counter medications, street drugs
Eating problems - overeating, undereating, appetite, vomiting (see also "Weight and diet issues")
Emptiness
Failure
Fatigue, tiredness, low energy
Fears, phobias
Financial or money troubles, debt, impulsive spending, low income
Friendships
Gambling
Grieving, mourning, deaths, losses, divorce
Guilt
Headaches, other kinds of pains
Health, illness, medical concerns, physical problems
Housework/chores-quality, schedules, sharing duties
Inferiority feelings
Interpersonal conflicts
Impulsiveness, loss of control, outbursts
Irresponsibility
Judgement problems, risk taking
Loneliness
Marital conflict, distance/coldness, infidelity's/affairs', remarriage, different expectations, disappointments
Memory problems
Menstrual problems, PMS, menopause
Mood swings
Motivation, laziness
Nervousness, tension
Obsessions, compulsions (thoughts or actions that represent themselves)
Oversensitivity to rejection
Pain, chronic
Panic or anxiety attack's
Parenting, child management, single parenthood
Perfectionism
Pessimism
Procrastination, work inhibitions', laziness
Relationship problems (with friends, with relatives, or at work)
School problems (see also "Career concerns...")
Self-Centeredness
Self-esteem
Self-neglect, poor self-care
Sexual issues, dysfunctions, conflicts, desire differences, other (see also "Abuse")
Shyness, oversensitivity to criticism
Sleep problems, too much too little, insomnia, nightmares
Smoking and tobacco use
Spiritual, religious, moral, ethical issues
Stress, relaxation, stress management, stress disorders, tension
Suspiciousness, distrust
Temper problems, self-control, low frustration tolerance
Thought disorganization and confusion
Threats, violence
Weight and diet issues
Withdrawal, isolating
Work problems, employment, workaholism/overworking, can't keep a job, dissatisfaction, ambition

Intake Form

Insurance Information

In Case of Emergency

PLEASE READ THE FOLLOWING CAREFULLY

Adult Information Form

Current Symptoms Checklist

School and Family History

Marital History

Mental Status

Level of Functioning

Adult Checklist of Concerns

Signature

	Hospital	Month/Year	Reason
1
2
3
4
5

	Type of Drug	How much?	How often?
1
2
3
4
5

	Type of Alcohol	How much?	How often?
1
2
3
4
5

	Schools	Years
1
2
3
4
5