Client Intake Form
Name
*
Date
*
/
Month
/
Day
Year
Date
Present Address
*
Primary phone
*
Format: (000) 000-0000.
Phone Type
*
Home
Cell
Work
Alternate phone
Format: (000) 000-0000.
Phone Type
Home
Cell
Work
Age
*
Sex
Birth Date
*
/
Month
/
Day
Year
Date
Social Security Number
*
Occupation
Total hours/week
Employed by
Phone
Format: (000) 000-0000.
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
Rows
Name
Age
Grade in school (last completed)
Occupation if out of school
Spouse
Child
Child
Child
Father
Mother
Relationship
Rows
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:
Rows
Now
Past
Abuse
Addictions (specify)
Anger
Anxiety
Blackouts
Children
Communication with others
Concentration
Depression
Eating
Education
Family
Fearful
Financial
Guilt
Headaches
Homicidal Thoughts
Irritability
Legal Issues
Marital
Memory
Obsessive Behavior
Obsessive Thoughts
Parents
Physical Problems
Sleep
Social Relationships
Stress
Substance Abuse
Suicidal Thoughts
Temper
Trusting Others
Work
Worry
Religious/Spiritual Issues
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
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