Counseling Services Intake Form
Thank you for reaching out to us. This form helps us understand you, your child, or your family and what support you’re hoping for. There are no right or wrong answers, and you may share as much or as little as you feel comfortable. Your responses are confidential and will help us provide the best care possible.
Client Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Prefer not to say
Pronouns
Race
Religion/Spirituality
Employer
Primary Care Physician
First Name
Last Name
Primary Care Physician Phone Number
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Relationship
*
Emergency Contact Phone
*
Insurance Information
Name of Insurance Provider
Name of Policy Holder
Policy Holder Social Security Number
Policy Holder Date of Birth
Insurance Member Identification Number
Insurance Member Group Identification Number
Does you or your child have secondary coverage? (i.e., Medicaid and private insurance). If so, please provide that info below.
Please upload a copy of the front and back of you or your child's current insurance card(s).
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Referral/Request Information
How did you hear about Born to Blossom or Elizabeth Parker, LPC?
Please Select
Internet search
Social media
Email
Word of mouth
Referral
Other
Reason for seeking counseling at this time:
*
What are you hoping counseling might help with? (Check any that apply)
*
Understanding emotions or reactions
Coping with stress, anxiety, or big feelings
Processing grief, loss, or life changes
Improving mood or motivation
Improving relationships
Feeling more stable and grounded
Building skills (communication, regulation, coping)
Supporting my child's emotional or behavioral needs
Not sure
Other
If "Other," please briefly explain:
Please list any concerns which you are or are have been seen for:
Current Concerns/ Challenges
Please check any areas that feel relevant right now for you or your child.
Adults: Please check any concerns you're experiencing currently
*
Depressed mood
Fatigue
Crying spells
Racing thoughts
Excessive worry
Loss of interest in things typically enjoyed
Unable to enjoy activities
Impulsivity
Increased irritability
Anxiety/panic
Anger outbursts
Disordered eating patterns
Self-harm or urges to harm self
Difficulty sleeping
Decreased need for sleep
Increased risky behavior
Avoidance
Increased libido
Decreased libido
Concentration/forgetfulness
Suspiciousness
Change in appetite
Excessive energy
Excessive guilt
Obsessive thoughts
Compulsive behaviors
Hearing/seeing things that others don't
Other
If "Other," please describe what you are experiencing:
Children/teens (parent-report): Please check any concerns you’re noticing for your child/teen currently
Difficulty managing big emotions
Anxiety, worry, or fears
Sadness, low mood, or frequent tearfulness
Low self-esteem or confidence
Grief or loss
Nightmares
Excessive guilt, shame, or negative self-talk
Family conflict or relationship stress
Big life change (recent move, family changes, etc.)
Peer conflict or bullying
Difficulty making or keeping friends
Social anxiety or withdrawal
School refusal or avoidance
Behavior concerns (aggression, tantrums, etc.)
Not sure/exploring whether counseling may help
Other
If "Other," please describe what your child/teen is currently experiencing:
If "Other," please describe what your child/teen is currently experiencing:
Have you/your child ever had feelings or thoughts that you/they didn't want to live?
*
Yes
No
Do you/does your child currently feel that you/they don't want to live or of attempting suicide?
*
Yes
No
If Yes to either of the 2 above questions, how often do you/they have these thoughts?
If Yes to either of the 2 earlier questions, when was the last time you/they had thoughts of dying or attempting suicide?
On a scale of 1 to 10, (ten being strongest) how strong are thoughts of dying or attempting suicide currently:
*
Weak
0
1
2
3
4
5
6
7
8
9
Strong
10
0 is Weak, 10 is Strong
Yes
No
Do you/does your child have feelings of hoplessness or wothlessness?
Have you/has your child ever tried to harm or kill yourself/themselves before?
Is there anything that would stop you/your child from killing yourself/themselves?
Psychological / Therapy History
Sharing any past supports helps us understand what you or your child have already tried and what has or hasn’t been helpful. You may skip any questions or share only what feels comfortable.
Has the client received counseling, therapy, or behavioral supports before?
Yes
No
Not sure / prefer not to say
If Yes, which types of support?
Counseling / therapy
Group therapy
Psychiatry / medication management
Intensive programs (IOP, PHP)
Speech therapy
Occupational therapy (OT)
Physical therapy (PT)
Applied Behavior Analysis (ABA)
Other
Are any supports currently ongoing?
Yes
No
Not sure
Would you like coordination with other providers?
Yes
No
Maybe
Was there anything you found helpful or unhelpful about past supports?
Current or Previous Therapist/Counselor, if applicable:
First Name
Last Name
Current or Previous Therapist/Counselor Phone Number, if applicable:
Medical / Medication Information
This helps your counselor understand any medications or health factors that may affect mood, focus, or daily functioning.
Date of last physical exam/wellness check:
-
Month
-
Day
Year
Date
Does the child or adult have any history of infectious diseases or other medical diagnoses we should know about?
Current medical problems/issues, if any:
Past medical problems, non-psychiatric hospitalizations, and/or surgeries:
Do you have any allergies? (If yes, please list them)
List all current prescription medications and how often you take them (excluding psychiatric medications):
If you have prescription medications you are currently taking, please list the name(s) of the doctor(s) who have prescribed them:
Psychiatric History
This helps us understand past levels of support so we can plan care thoughtfully.
Have you ever been treated as an outpatient for mental health concerns?
Yes
No
If yes, please describe when, by whom, and nature of treatment:
Have you ever been treated as an inpatient at a psychiatric facility?
Yes
No
If yes, please describe when, by whom, and nature of treatment:
Mental Health-Related Medications
This section helps us understand any medications that may affect mood, sleep, focus, emotions, or behavior. Sharing this information is optional, and you may include only what feels comfortable.
Are you or your child currently taking any medications related to mental health, mood, attention, sleep, or behavior?
Yes
No
Not sure/prefer not to say
If yes, please list all current mental health-related prescription medications and how often you/your child take(s) them:
Who currently manages or prescribes these medications?
Primary care provider
Psychiatrist
Nurse practitioner/PA, Psychiatric Nurse Practitioner, etc.
Other
Has the client taken mental health-related medications in the past?
Yes
No
Not sure
If yes, please list the medication(s) that were taken, what was helpful or unhelpful about the medication(s), and the reason you stopped the medication (if known):
Is there anything else you'd like us to know about your/your child's psychiatric medications?
If you have ever taken any of the following medications, please indicate the dates and daily dosage.
Have you ever taken it?
Dates
Dosage
Side Effects?
Prozac (fluoxetine)
Zoloft (sertraline)
Luvox (fluvoxamine)
Paxil (paroxetine)
Celexa (citalopram)
Lexapro (escitalopram)
Effexor (venlafaxine)
Cymbalta (duloxetine)
Wellbutrin(bupropion)
Remeron (mirtazapine)
Serzone (nefazodone)
Anafranil (clomipramine)
Pamelor (nortrptyline)
Tofranil (imipramine)
Elavil (amitriptyline)
Tegretol (carbamazepine)
Lithium
Depakote (valproate)
Lamictal (lamotrigine)
Tegretol (carbamazepine)
Topamax (topiramate)
Seroquel (quetiapine)
Zyprexa (olanzepine)
Geodon (ziprasidone)
Abilify (aripiprazole)
Clozaril (clozapine)
Haldol (haloperidol)
Prolixin (fluphenazine)
Risperdal (risperidone)
Ambien (zolpidem)
Sonata (zaleplon)
Rozerem (ramelteon)
Restoril (temazepam)
Desyrel (trazodone)
Adderall (amphetamine)
Concerta (methylphenidate)
Ritalin (methylphenidate)
Strattera (atomoxetine)
Xanax (alprazolam)
Ativan (lorazepam)
Klonopin (clonazepam)
Valium (diazepam)
Tranxene (clorazepate)
Buspar (buspirone)
Family Mental Health History
Many people have family members with a range of emotional or mental health experiences. Sharing this information is optional and simply helps us get a fuller picture.
Has anyone in your family been diagnosed with or treated for:
Depression
Anxiety
Anger
Suicide (attempted or completed)
Schizophrenia
Bipolar disorder
Post-traumatic stress
Substance abuse
Obsessive-Compulsive Disorder
Autism
ADHD
Intellectual Disability
Learning Disorder
Anger
Personality Disorder
Other
Has any family member been treated with a psychiatric medication? If yes, who was treated, what medications did they take, and how effective was the treatment?
Exercise Level
This section helps us understand how movement fits into daily life, as it can sometimes affect mood, energy, and stress. You may share only what feels comfortable.
Adults: Do you exercise regularly?
Yes
No
How much time each day do you exercise?
Substance Use History
This section helps us understand any use of substances that may affect mood, behavior, safety, or overall well-being. There is no judgment about substance use. Sharing this information is optional and helps us provide the most supportive care.
Check if you have ever tried the following or are you currently using the following:
Methamphetamine
Cocaine
Stimulants (pills)
Heroin
LSD or Hallucinogens
Marijuana
Pain killers (not as prescribed)
Methadone
Tranquilizer/sleeping pills
Alcohol
Ecstasy
Other
How many caffeinated beverages do you drink a day?
Tobacco Use History
This section helps us understand any use of tobacco or nicotine products, as these can sometimes affect mood, health, or stress. There is no judgment about tobacco use. Sharing this information is optional and helps us provide the most supportive care.
Have you ever smoked cigarettes?
Yes, as a habit
Yes, only socially/not as a habit
No
How many packs per day?
How many years?
Family Background and Childhood History:
Everyone’s family and childhood experiences are different. This section is optional and simply helps us get a fuller picture to support care.
Were you adopted?
Yes
No
For children/teens: Was the child adopted?
Yes
No
Where did you grow up?
Did your parents divorce?
Yes
No
My parents were never married
Other
Do you have siblings, and if so, how many?
Some people have experienced difficult or harmful events during childhood, and others have not. This question is optional and meant to help your counselor understand your early experiences so we can provide the best support. You may share as much or as little as feels comfortable, and you can skip this question entirely. Do you have a history of being abused emotionally, sexually, physically or by neglect? If yes, please describe when, where, and by whom.
For children/teens (parent-report): To the best of your knowledge, has your child/teen ever experienced harm, neglect, or exploitation within their family or caregiving environment? If yes, please describe when, where, and by whom.
Educational History
This helps us understand learning experiences and current supports.
What is your/your child's highest grade completed?
Children/teens: If currently in school, what is the name of the school? This is only so that your counselor has shared knowledge of the child/teen's current educational supports.
Children/teens: If currently in school, what is the name of their teacher? This is only so that your counselor has shared knowledge of the child/teen's current educational supports.
Is there anything you would like us to know about the child/teen or adult's educational or school history?
Personal History
People have many different life situations, and there are no right or wrong answers here. Sharing this information is optional and helps us better understand your daily life and support system.
Are you currently:
Working full-time
Student
Working part-time
Unemployed
Disabled
Retired
Other
Are you currently:
Single
In a committed relationship/ partnered
Partnered
Married/ domestic partnership
Divorced
Widowed
Separated
It's complicated/ prefer not to label
Co-parenting/ blended family
Other
Do you have any children?
Yes
No
Stepchildren
Other
Please list ages and gender:
Have you ever been arrested? There are no judgments about arrests.
Yes
No
Additional information
Emergency Contact
First Name
Last Name
Phone Number
Date
-
Month
-
Day
Year
Date
Signature
Guardian Signature (if under age 18)
Submit
Should be Empty: