Stackbit - Counseling Intake Form

Personal Information
Patient Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Email
example@example.com
Primary Phone
Preferred Method of Contact

E-mailPhone
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:*

OnlineIn PersonBoth
Marriage & Family Information
Marital Status
Name of Spouse/Significant Other

First NameLast 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?

YesNoUnsure
Medical History
Please select all the apply.

NoneAllergiesAnemiaAnginaAnxietyArthritisAsthmaAtrial FibrillationBenign ProstaticHypertrophyBlood ClotsCancerCerebrovascular AccidentCronary Artery DiseaseCOPD (Emphysema)Crohn's DiseaseDepressionDiabetesGallbladder DiseaseGERD (Reflux)Hepatitis CHyperlipidemiaHypertensionIrritable Bowel DiseaseLiver DiseaseMigraine HeadachesMyocardial InfarctionOsteoarthritisOsteoporosisPeptic Ulcer DiseaseRenal DiseaseSeizure DisorderThyroid DiseaseOther
Do you drink alcohol?

YesNoFormer User
Do you use drugs or take any unprescribed medications?

YesNoFormer User
If yes, please specify what drugs/medications and their frequency.
Have you been convicted of any alcohol or drug related charges?

YesNo
If so, please explain the circumstances.
Are you currently taking any prescription medication(s)?

YesNo
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)

HomeWorkMarriageRelationshipsGod/FaithOther
How long has this been going on?
Please rate the severity of your present concerns.

MildModerateSevereTotally 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 PastAngerAnxietyApathyBad MemoriesBitternessBlackouts/Memory LossCaring for ParentsChronic PainCommunication IssuesCompulsionsConflict ResolutionCrying SpellsDepressionDebtDeathDelusionsDiscontentmentDivorceDoubt SalvationEating DisorderEmpty NestEnvyFamily ConflictFearFinancial ManagementForgivenessGreedGriefGuiltHallucinationsHealth ConcernsHearing VoicesHumilityIdentityImpatienceInfidelityInfertilityInsecurityInsomniaJealousyJudgmentalLifestyle ChangeLonelinessLoss of AppetiteLoss of InterestLyingManipulationMarital IntimacyMoodinessNightmaresObsessive CompulsivePanic AttacksParanoiaParentingPeer PressurePeople PleasingPerfectionismPornographyPridePrioritiesProcrastinationPurpose (Lack Of)Racing ThoughtsRebellionRegretsRejectionRelationshipsRespectSchoolSelf ControlSelfishSexual IssuesShameSocial AnxietySpiritual GrowthSubmissionSuicidal ThoughtsTime ManagementTiredTrustWorkOther
What do you expect from this counseling?
Have you seen a counselor, psychologist, psychiatrist, or other mental health professional before?

YesNo
What was the name of the provider?

First NameLast 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

MonthDayYear
Date
Signature

Clear
Please verify that you are human*
Should be Empty:

	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday
Morning
Afternoon
Evening

Personal Information

Marriage & Family Information

Medical History

Self Evaluation