Counseling Intake Form
Your 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
Home Phone
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Preferred Method of Contact
E-mail
Home Phone
Cell Phone
Marital Status
Single
Married
Divorced
Widowed
Child/Children's Name & Age
Employment
Employed
Unemployed
Disabled
Retired
Student
Emergency Contact Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Relationship
Medical History
Illnesses or Conditions
None
Prefer Not to Answer
List illnesses or conditions below
Allergies
Do you use tobacco?
No
Daily
Weekly
Less
Former User
Do you use alcohol?
No
Daily
Weekly
Less
Former User
Are you currently taking prescription medication?
Yes
No
Family history
Adopted
Alcoholism
Depression
Mental Illness
Mental Health History
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?
Yes
No
Reason for seeking help
Average hours of sleep per night
Additional comments or concerns
Spiritual Health History
Are you a Christian?
When did you become a Christian?
Before becoming a Christian, what was your belief system?
What is your church affiliation?
How often do you attend?
Was Christianity a part of your family life growing up?
If married, is your spouse a Christian?
Counselling Objectives
Why you are seeking counselling?
What do you expect from this counselling?
*Your signature below indicates that the information you have provided above is truthful.
Date
-
Month
-
Day
Year
Date
Signature
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