Stackbit - Counseling Intake Form

Personal Information
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
Primary Phone
Preferred Method of Contact

E-mail Phone
Employment
What type of counseling are you seeking? *

Select days/times for your appointment availability (please click all that apply)

I would prefer counseling to be: *

Online In Person Both
Marriage & Family Information
Marital Status
Name of Spouse/Significant Other

First Name Last Name
Age of Spouse/Significant Other
If applicable, number of children and ages.
Please separate names using a comma
Is your spouse/significant other willing to come to counseling?

Yes No Unsure
Medical History
Please select 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
Do you drink alcohol?

Yes No Former User
Do you use drugs or take any unprescribed medications?

Yes No Former User
If yes, please specify what drugs/medications and their frequency.
Have you been convicted of any alcohol or drug related charges?

Yes No
If so, please explain the circumstances.
Are you currently taking any prescription medication(s)?

Yes No
If yes, please specify which medications.
Self Evaluation

Please share as much as you are comfortable with.
Why are you seeking treatment?
What area(s) of your life does this impact most? (Select all that apply)

Home Work Marriage Relationships God/Faith
How long has this been going on?
Please rate the severity of your present concerns.

Mild Moderate Severe Totally Incapacitating
Please indicate which of the following areas are currently problems for you. (Select all that apply)

Abuse (Alcohol/Drug) Abuse (Physical) Abuse (Sexual) Abuse (Verbal) Abuse in the Past Anger Anxiety Apathy Bad Memories Bitterness Blackouts/Memory Loss Caring for Parents Chronic Pain Communication Issues Compulsions Conflict Resolution Crying Spells Depression Debt Death Delusions Discontentment Divorce Doubt Salvation Eating Disorder Empty Nest Envy Family Conflict Fear Financial Management Forgiveness Greed Grief Guilt Hallucinations Health Concerns Hearing Voices Humility Identity Impatience Infidelity Infertility Insecurity Insomnia Jealousy Judgmental Lifestyle Change Loneliness Loss of Appetite Loss of Interest Lying Manipulation Marital Intimacy Moodiness Nightmares Obsessive Compulsive Panic Attacks Paranoia Parenting Peer Pressure People Pleasing Perfectionism Pornography Pride Priorities Procrastination Purpose (Lack Of) Racing Thoughts Rebellion Regrets Rejection Relationships Respect School Self Control Selfish Sexual Issues Shame Social Anxiety Spiritual Growth Submission Suicidal Thoughts Time Management Tired Trust Work
What do you expect from this counseling?
Have you seen a counselor, psychologist, psychiatrist, or other mental health professional before?

Yes No
What was the name of the provider?

First Name Last Name
If different from the above, what was your reason for seeking help?
On average, how many hours of sleep do you get per night?
Any additional comments or concerns?
How did you hear about us? *
*Your signature below indicates that the information you have provided above is truthful.
Date

Month Day Year
Date
Signature

Clear
Should be Empty:

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Morning
Afternoon
Evening

Personal Information

Marriage & Family Information

Medical History

Self Evaluation