Counseling Intake Form

Counseling Intake Form

Please answer the following questions to the best of your abilities. These questions are to help the therapist with the therapy process. This information is held to the same standards of confidentiality as our therapy.
Patient Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Age
Marital Status
Email
example@example.com
Gender
Number of Children
Children Ages
Work Phone
Cell/ Other
Preferred Method of Contact *NOTE: Emails may not be confidential

E-mailHome PhoneCell Phone
Emergency Contact Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Relationship
Referred By
Are you currently receiving psychological services, professional counseling, psychiatric services, or any other mental health services?

YesNo
Reason for change:
Are you currently taking any psychiatric prescription medication?

YesNo
If yes, please list:
Have you ever been prescribed psychiatric prescription medication in the past?

YesNo
If yes, please list:
Have you been psychiatrically hospitalized in the past?

YesNo
If yes, please list dates and locations:
Are you currently having feelings of self-harm?

YesNo
Have you ever attempted or experienced periods in the desire to self-harm?

YesNo
General Health Information
Please provide the name, address and telephone number for your primary care physician:
How is your physical health at the present time?

PoorUnsatisfactorySatisfactoryGoodVery Good
Please list any persistent physical symptoms or health concerns (e.g. chronic pain, headaches, hypertension, diabetes, thyroid dysfunction, etc.):
Are you on any medication for physical/medical issues?

YesNo
If yes, please list:
Are you having any problems with your sleep habits?

YesNo
If yes, click those that apply:

Sleep too muchSleep too littlePoor qualityDisturbing dreamsOther
Are there any changes or difficulties with your eating habits?

YesNo
If yes, click those that apply:

Eating lessEating moreBingeingOther
Have you experienced a weight change in the last two months?

YesNo
Do you exercise regularly?

YesNo
If yes, how many days per week do you exercise?
How many minutes/hours per session:
Do you consume alcohol regularly?

YesNo
In one month, how many times do you have four or more drinks in a 24-hour period?
How often do you engage in recreational drug use?

DailyWeeklyMonthlyRarelyNever
What kinds of recreational drugs do you use:
Are you currently in a romantic relationship?

YesNo
If yes, how long have you been in this relationship?
On a scale from 1-10 (10 being great), how would you rate the quality of your relationship?
In the last year, have you had any major life changes (e.g. new job, moving, illness, relationship change, etc.)?
Quick Check

Check the issues below that apply to you.
Please check all the apply

NoneDepressed MoodPanic AttacksMemory LapseRelationship ProblemsMood SwingsPhobiasTrouble planningHallucinationsRapid SpeechRepetitive BehaviorsSleep DisturbanceEating difficultiesSuicidal ThoughtsAnxietyTime lossBody ComplaintsHomicidal thoughtsExcessive WorryAlcohol/Drug abuseTraumatic Event
Have you felt depressed recently?

YesNo
If yes, for how long?
Have you had any suicidal thoughts recently?

YesNo
If yes, how often?

FrequentlySometimesRarely
Have you ever had suicidal thoughts in your past?

YesNo
If yes, how long ago?
How often did you have these thoughts?

FrequentlySometimesRarely
Family Mental Health History

The following is to provide information about your family history. Please mark each as yes or no. If yes, please indicate the family member affected.
Depression

YesNo
Suicide

YesNo
Anxiety Disorders

YesNo
Bipolar Disorder

YesNo
Panic Attacks

YesNo
Alcohol/Substance Abuse

YesNo
Eating Disorder

YesNo
Trauma History

YesNo
Domestic Violence

YesNo
Sexual Abuse

YesNo
Obesity

YesNo
Obsessive Compulsive Behavior

YesNo
Schizophrenia

YesNo
Religious/Spiritual Information
Do you practice a religion?

YesNo
If yes, what is your faith?
Occupational Information
Are you currently employed?

YesNo
If yes, who is your employer?
What is your position?
Are you happy in your current position?

YesNo
Does your work make you stressed?

YesNo
If yes, what are your work-related stressors?
Other Information
List your strengths and what you like most about yourself:
List areas you feel you need to develop
What are some ways you cope with life obstacles and stress?
What are your goals for therapy/what would you like to accomplish?
By signing below, I am acknowledging that I have chosen to receive mental health services in the form of evaluation and Christian counseling from Archie R. Green, BCCC, AACC, MAPC. My decision is voluntary and I understand that I may terminate these services at any time. I also understand that during the course of treatment I may need to discuss material of an upsetting nature in order to resolve my problems. Further, I understand it cannot be guaranteed that I will feel better after completion of treatment. Client(s) agrees to 4-prepaid (see attached scale) 50-60 mn counseling sessions. This includes one (1) follow-up session 90 after the final in-person session.

*Your signature below indicates that the information you have provided above is truthful.
Date

MonthDayYear
Date
Signature

Powered by Jotform SignClear
Should be Empty:

Counseling Intake Form

Emergency Contact Information

General Health Information

Quick Check

Family Mental Health History

Religious/Spiritual Information

Occupational Information

Other Information