Client Intake Form for Individual Counseling

Client Intake Form
Name *
Date *

Month Day Year
Date
Present Address *
Primary phone *
Phone Type *

Home Cell Work
Alternate phone
Phone Type

Home Cell Work
Age *
Sex
Birth Date *

Month Day Year
Date
Social Security Number *
Occupation
Total hours/week
Employed by
Phone
Referred by
Education (Check Highest Level Completed) *

Middle Some High School High School Graduate Some College Bachelors Masters Doctorate Other
Religious Affiliation
Are Parents

Married Divorced Separated Widowed
Presently Living With

Parents Spouse Roommate Alone Other

Relationship

	Name	Age	Grade in school (last completed)	Occupation if out of school
Spouse
Child
Child
Child
Father
Mother

Relationship

	Name	Age	Grade in school (last completed)	Occupation if out of school
Brother(s)
Sister(s)
Step-father
Step-mother
Step-brother(s)
Step-sister(s)

Have any of your family had counseling before?

Yes No
If yes, please describe
Any history of drug or alcohol abuse in your family?

Yes No
If yes, please describe
Anything important that happened in your childhood that you think has affected your life?

Yes No
If yes, please describe
Do you use alcohol or drugs?

Yes No
If yes, please describe
Have you ever had any physical problem that you feel has affected your life?

Yes No
If yes, please describe
What medications are you presently taking?
Have you ever experienced any sexual difficulties?

Yes No
If yes, please describe
Have you ever had counseling before?

Yes No
If yes, please describe and list name of person(s):
How many hours of sleep do you get nightly?
Children

Abuse Addictions (specify) Marital Now Memory Past Difficulty With: Obsessive thoughts Obsessive behavior Parents Anxiety Anger Past Now Physical problems Blackouts

Difficulty With:

In your own words, briefly describe the main problem that prompted you to seek counseling at this time.
Have there been times when the problem got better or disappeared?

Yes No
If so, please describe:
What do you think helped?
Were there times when the problem was especially bad?

Yes No
If so, when? What made it bad?
Are there other people who play a major role in causing your problems?

Yes No
Explain briefly:
Is there anything else which you believe it might be important for your counselor to know at this time?
What are you wanting from counseling? Your goals?
Please complete the following.
The most important thing to me is
I worry about
What I do best is
I have sometimes felt guilty about
I have been criticized for
What makes me angry is
My biggest mistakes were
My job
What makes me nervous is
My personality would be better if
I often felt that my mother
Jesus Christ is
My temper
My childhood
Prayer is
My biggest disappointment
To me, sex is
I would be better liked if
I often felt that my father
God to me is
My children (child) / (brothers and sisters)
Women are
What hurts me most is
My biggest problem in life is
Men are
Should be Empty:

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