Jireh Counseling Center Intake Form
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
Marital Status
Please Select
Single
Married
Divorced
Widowed
Email
example@example.com
Employment
Please Select
Employed
Unemployed
Disabled
Retired
Student
Name of Employer
Referral Name
First Name
Last Name
Home Phone
Cell Phone
Preferred Method of Contact
E-mail
Home Phone
Cell Phone
Emergency Contact Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Relationship
Insurance Information
Name of Insurer
First Name
Last Name
Insurer Phone Number
Subscriber Name
First Name
Last Name
Subscriber Date of Birth
-
Month
-
Day
Year
Date
Subscriber Relationship to Patient
Group Number
Policy Number
Medical History
Please check 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
Other
Do you use tobacco?
No
Daily
Weekly
Less
Former User
Do you use alcohol?
No
Daily
Weekly
Less
Former User
Caffeine use?
No
Daily
Weekly
Less
Former User
Are you currently taking prescription medication?
Yes
No
Mental Health History
Why you are seeking treatment?
What do you expect from this counselling?
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?
Yes
No
Therapist Name
First Name
Last Name
Reason for seeking help
Average hours of sleep per night
Please describe any other experiences you have had problems with
Additional comments or concerns
*Your signature below indicates that the information you have provided above is truthful.
Date
-
Month
-
Day
Year
Date
Signature
Submit
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